An Application Packet Page 11
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14Parent Responsibility Agreement
Informal Child Support Form
(DO NOT USE THIS FORM IF YOU ALREADY HAVE FILED WITH THE ATTORNEY GENERAL’S
OFFICE OR PRIVATE CHILD SUPPORT AGENCY)
Case Number:
State law requires that any family receiving child care assistance comply with the Parent Responsibility Act.
This Act includes receiving child support for each individual child.
When to use this form
: This form is to be used ONLY in the event that there is an informal child support
arrangement between you and the absent parent(s), not filed with the Attorney General’s office or private child
support agency.
Who completes this form
: This form is to be completed by the parent NOT living in the household, the absent
parent.
IMPORTANT: If the children in the household have informal arrangements with different absent parents, we
need verification of support for each child.
Please make copies of this form for each child’s absent parent to complete and sign.
Name of custodial parent (first, last):
Name of absent parent (first, last):
Name of Child or Children:
Below list your payment history for the last three months:
Month
Amount of Monthly Financial Support ($)
SIGNATURES
Custodial Parent Signature
Date
Absent Parent Signature (must be Notarized)
Date
State of ___________________
County of ___________________
Notary Public's Signature
___________________, personally appeared before
me, and being first duly sworn declared that he/she
Date___________________________
signed this application in the capacity designated, if
any, and further states that he/she has read the
above application and the statements therein
contained are true.
(Personalized Seal)
Rev. 11-13
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