Form Csed 04-1603 - Child Support Information Form Page 3
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4MARITAL STATUS INFORMATION
Please provide the following information about the parents of the child(ren) listed on page one of this form:
( ) Married:
Date:
Place:
( ) Separated (Whether married or not): Date:
Place:
( ) Divorce Pending: Date filed:
Place:
_________________
( ) Divorced: Date final:
Place:
_________________
( ) Never Married If marked, has paternity been legally established by either court or administrative order for
each child listed on page 1? YES
NO
PROVIDE COPY OF PATERNITY ORDER, DIVORCE/DISSOLUTION DECREE, AND ALL SUPPORT
ORDERS
SUPPORT PAYMENT INFORMATION
IMPORTANT!
When you receive Temporary Assistance you sign over to CSED any child support or alimony payments owed to you. The
money is used to pay back the state for the assistance you get. This means that any time that you are given child support
money while you are getting Temporary Assistance payments, you must turn in the entire payment to CSED. This is true
whether or not there is an order for child support in effect. You should also be aware that if the other parent is behind in
child support payments when you begin receiving Temporary Assistance, the entire amount owed to you may now belong
to the state, depending upon how much money you receive in Temporary Assistance. This is a requirement of the Alaska
State Statute 47.27.040
PLEASE LIST THE LAST CHILD SUPPORT PAYMENTS YOU HAVE RECEIVED:
$
Date received
$
Date received
$
Date received
$
Date received
$
Date received
$
Date received
IF YOU HAVE A CHILD SUPPORT ORDER, PLEASE COMPLETE THE FOLLOWING SECTION:
The first month you were owed child support was
year
.
The monthly amount of child support owed is $
. Has this amount ever changed? YES
_
NO
_
The amount of back support owed as of today is $
.
The next monthly payment is due on
.
IF YOUR ORDER ALLOWS CREDIT FOR TIMES WHEN THE CHILD(REN) VISIT WITH THE OTHER PARENT PLEASE
COMPLETE THE FOLLOWING:
Dates of last 2 periods of visitation: From
to
; From
to
.
CUSTODY INFORMATION
HAS CUSTODY OF THE CHILDREN BEEN LEGALLY DETERMINED? YES
NO
DO YOU HAVE: FULL CUSTODY___________SHARED CUSTODY __________DIVIDED CUSTODY
(Divided custody is when each parent has custody of at least one or more of the children of the relationship)
Under penalty of perjury, I attest that the above information is true and complete.
Signature
Date
CSED 04-1603 (Rev 09/13/00) Page 3 of 3
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