Form Cssd 04-1606b - Statement Of Support Received
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2STATEMENT OF SUPPORT RECEIVED
See instructions on the next page.
If you received no support, please submit this statement with the “no support received” options checked in Items 4 and 5.
1. Your name ____________________ CSSD Case # ____________ Noncustodial parent’s name ___________________
2. You are the custodian of these minor children:
Child’s full name
Date of birth
Child’s full name
Date of birth
Check all the appropriate boxes in items 3-6, and complete the table below (or submit separate pages if necessary).
3.
An administrative order from
A court order directs that you are
No administrative or court
CSSD or another child support
OR
entitled to receive
OR
order for child support is in
agency directs that you are
child support
effect at this time.
entitled to receive child support.
alimony
spousal support)
(
4.
List in the table below the
If you aren’t sure how much
You have received no
child support payments you have
OR
child support you’ve received from
child support from the
OR
received directly from the
the noncustodial parent, list your
noncustodial parent.
noncustodial parent. Don’t forget
best estimate by month and year in
to indicate the year(s).
the table below (or on a separate
page).
5.
List in the table below the
If you aren’t sure how much
You have received no
alimony (spousal support) you
OR
alimony (spousal support) you’ve
OR
alimony (spousal support)
have directly from the
received from the noncustodial
from the noncustodial parent.
noncustodial parent. Don’t forget
parent, list your best estimate by
to indicate the year(s).
month and year in the table below
(or on a separate page).
6. If a child support order is already in effect, did you live with the other parent (or has the other parent had custody of the
children) at any time since the order was issued?
Yes
No
If your answer is yes, attach a description of the
time periods when you lived together (or when the other parent had custody) since the child support order was issued.
Year:
Year:
Year:
Child Support
Alimony/
Child Support
Alimony/
Child Support
Alimony/
Spousal
Spousal
Spousal
Jan
Jan
Jan
Feb
Feb
Feb
Mar
Mar
Mar
Apr
Apr
Apr
May
May
May
Jun
Jun
Jun
July
July
July
Aug
Aug
Aug
Sep
Sep
Sep
Oct
Oct
Oct
Nov
Nov
Nov
Dec
Dec
Dec
Signature
Date _______________________
______________________________________________
CSSD main office mailing address:
th
550 W 7
Ave Suite 310
Anchorage AK 99501-6699
[
CSSD 04-1606b (Rev. 01/13/04) (2 p.)
Statement of Support Received (3 yr version)
Page 1 of 2
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