Child Support Case Registration And Payment Form (Css-1) Page 2
Download a blank fillable Child Support Case Registration And Payment Form (Css-1) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Child Support Case Registration And Payment Form (Css-1) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ORDER INFORMATION: Hearing Date: ______________Judge/Magistrate: ___________________________
HAS WAGE ASSIGNMENT BEEN ORDERED BY THE COURT
?
[ ] YES
[ ] NO
ONGOING ORDERS
CHILD SUPPORT
FOR
ARREARS - ESTABLISHED BY COURT ORDER
SPOUSAL SUPPORT, CASH MEDICAL & ARREARS
E
STABLISHED
TYPE
AMOUNT
ORDER
ORDER
:
ARREARS
(
)
FOR
BALANCE
AS OF
DATE
EFFECTIVE DATE
SUSPEND DATE
CHILD SUPPORT-
CHILD
$___________________ ______________ ___________
to CP/ Non Welfare $ ______________
__________
SUPPORT**
/
-
/
OWED
WEEK
BI
WK
MTH
**
EXCLUSIVE OF CASH MEDICAL ORDER
Owed to STATE (Welfare) $ ______________
__________
CASH:
$ __________________ ______________ ___________
MEDICAL
/
-
/
WEEK
BI
WK
MTH
CP M
A
* *
$ ______________
__________
EDICAL
RREARS
ARREARS: $___________________ ______________ ___________
S
C
M
……
$ ______________
__________
TATE
ASH
EDICAL
/
-
/
WEEK
BI
WK
MTH
S
………… $_______________ __________
POUSAL SUPPORT
SPOUSAL: $___________________ ______________ ___________
/
-
/
WEEK
BI
WK
MTH
PAST
P
L
AST
IABILITY (RIGL 15-8-4)
LIABILITY
$___________________ ______________ ___________
O
CP…..…….
$ _______________ ___________
WED TO
pursuant to
/
-
/
WEEK
BI
WK
MTH
O
STATE ..… $ _______________ ___________
WED TO
RIGL 15-8-4
**CP medical arrears, including amounts due for un-reimbursed medical/dental
expenses per court order to be paid through the Family Court Collection Unit
INTEREST on ARREARS
:
[ ]
[ ] I
INTEREST ON ARREARS SHALL ACCRUE
NTEREST ON ARREARS SHALL NOT ACCRUE
MEDICAL INSURANCE INFORMATION
I
COURT ORDER
/
/
YES
NO
S THERE A
FOR EITHER PARTY TO OBTAIN
MAINTAIN INSURANCE FOR CHILD
CHILDREN
I
,
?
CUSTODIAL
NON CUSTODIAL
F YES
WHICH PARTY WAS ORDERED TO MAINTAIN THE INSURANCE
A
?………...
YES
NO
RE ALL CHILDREN IN THIS CASE CURRENTLY COVERED UNDER A MEDICAL INSURANCE PLAN
I
YES,
’
? (
)
F
HOW IS THE CHILD
S INSURANCE BEING PROVIDED
CHECK ALL THAT APPLY
[ ] C
P
S
USTODIAL
ARENT THRU EMPLOYER SPONSORED PLAN WITHOUT ANY
TATE SUBSIDY
[ ] N
C
P
ON
USTODIAL
ARENT THRU AN EMPLOYER SPONSORED PLAN
[ ] S
M
R
C
/ R
S
/ RIW
TATE
EDICAID
ITE
ARE
ITE
HARE
ORKS
N
C
P
,
:
IF THE
ON
USTODIAL
ARENT DOES NOT COVER THE CHILD THROUGH AN EMPLOYER SPONSORED PLAN
ANSWER THE FOLLOWING BELOW
D
NCP
………………………
YES
NO
OES
EMPLOYER OFFER FAMILY HEALTH INSURANCE
I
(5%
NCP
)?………
YES
NO
S COST OF INSURANCE REASONABLE
OR LESS OF
GROSS INCOME
I
NCP? …………...
YES
NO
S THERE A COURT ORDER FOR CASH MEDICAL CONTRIBUTION BY
IMPORTANT NOTICE - SELECTION OF SERVICE LEVEL
I
W
(RI W
)
S
C
C
P
(CCAP)
N ANY CASE WHERE A CHILD RECEIVES PUBLIC BENEFITS THROUGH
ELFARE
ORKS
OR THROUGH THE
TATE
HILD
ARE
ROGRAM
ALL CHILD
RI F
C
FULL SERVICE
.
SUPPORT PAYMENTS MUST BE MADE THROUGH THE
AMILY
OURT AND THE OBLIGEE MUST SELECT
LEVEL
I
S
M
(RITECARE / RITESHARE)
“F
S
”
N ANY CASE WHERE A CHILD RECEIVES ONLY
TATE
EDICAID
THE OBLIGEE MUST SELECT EITHER
ULL
ERVICE
OR
“M
O
”
B
R
O
.
EDICAL
NLY
SERVICE LEVEL AND MAY NOT SELECT
OOKKEEPING OR
EGISTRATION
NLY
I
,
F
S
, B
O
R
I
N ANY CASE WHERE A CHILD RECEIVES NO PUBLIC BENEFITS
THE OBLIGEE MAY ELECT
ULL
ERVICE
OOKKEEPING
NLY OR
EGISTRATION OF
NFORMATION
O
.
NLY
I
. B
I
/
ELECT THE SERVICE LEVEL MARKED BELOW
Y SIGNING THIS FORM
AUTHORIZE THE RI FAMILY COURT THROUGH ITS COOPERATIVE AGREEMENT WITH DHS
RI OFFICE OF
(OCSS)
/
.
CHILD SUPPORT SERVICES
TO COLLECT MY CHILD SUPPORT AND
OR MEDICAL SUPPORT AS MAY BE APPROPRIATE
SERVICES
[
] FULL
– S
RI F
C
(OCSS)
UPPORT PAID THROUGH THE
AMILY
OURT AND OFFICE OF CHILD SUPPORT SERVICES
TO PROVIDE FULL ENFORCEMENT
$20
,
ATTACH
APPLICATION FEE TO NEW APPLICATIONS WHEN CHILD DOES NOT RECEIVE WELFARE
STATE MEDICAL ASSISTANCE OR CCAP
MEDICAL ONLY
[
]
– C
A
B
HECK EITHER
OR
BELOW
T
/
S
M
A
O
(R
C
R
S
) AND I
OCSS
C
S
HE CHILD
CHILDREN RECEIVE
TATE
EDICAL
SSISTANCE
NLY
ITE
ARE OR
ITE
HARE
DO NOT WANT
SERVICES FOR
HILD
UPPORT
A. [ ] I
OCSS
DO NOT WANT
SERVICES TO ENFORCE THE CHILD SUPPORT PORTION OF THE ORDER AND ONLY MEDICAL ORDERS WILL BE PAID THROUGH FAMILY
COURT OR
OCSS
ENFORCED BY
B. [ ] B
C
M
S
F
C
I
OCSS
OTH
ASH
EDICAL AND
UPPORT WILL BE PAID THROUGH
AMILY
OURT BUT
DECLINE
SERVICES TO ENFORCE THE SUPPORT PORTION OF THE
O
.
RDER
BOOKKEEPING ONLY
[
]
- P
F
C
,
OCSS
AYMENT TO BE MADE THROUGH THE
AMILY
OURT
BUT NO
SERVICES TO ENFORCE ORDER
REGISTRATION
ORDER INFORMATION ONLY
[
]
– P
RI F
C
;
OF
AYMENTS WILL NOT BE SUBMITTED THROUGH THE
AMILY
OURT
THERE ARE NO PUBLIC
BENEFITS FOR ANY CHILD IN THE CASE
: ______________________ C
P
/ O
: ________________________________________________________
DATE
USTODIAL
ARENT
BLIGEE SIGNATURE
P
O
.
AYMENTS TO THE
BLIGEE CANNOT BE DISBURSED UNLESS THIS SECTION IS COMPLETE
OBTAIN MORE INFORMATION AND AN APPLICATION FOR RI CHILD SUPPORT SERVICES (OCSS) AT
ADVERTISEMENT
0 votes
Related Articles
Related forms
Instructions For Preparation Of Transfer Agent Registration And Amendment Form Ta-1 - Federal Deposit Insurance Corporation - 2016
Legal
Form Csed 04-1017 - Application For Child Support Enforcement Services And Affidavit Of Support Received And Affidavit And Request For Address Confidentiality - Alaska Division Of Child Support Enforcement
Legal
Form Cse-1160a Forpf - Request To Close Child Support Case/solucitud Para Cerrar El Caso De Sustento De Menores
Legal
Related Categories
Parent category: Legal