Non-Custodial Parent Child Support Statement
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1ARKANSAS DEPARTMENT OF HUMAN SERVICES
Division of Child Care and Early Childhood Education
CHILD CARE ASSISTANCE PROGRAM
NON-CUSTODIAL PARENT CHILD SUPPORT STATEMENT
For persons who are divorced or unmarried, within six (6) months of receiving child care benefits, you must
document that you are either receiving child support or show proof of an open Child Support case. If you receive
child support directly from the non-custodial parent, you may have that parent complete this form and have it
notarized. This form must be submitted, along with copies of checks or money orders to verify child support
payments. The amount of child support you receive must at least be equal to the minimum amount per child on
the Family Support Chart set by the Office of Child Support Enforcement. If you receive child support through
the Office of Child Support Enforcement or through a court, this form does not need to be completed. If you are
not a single parent of a child in your household, you may disregard this form.
____________________________
_______________________
________________
Custodial Parent Name
Social Security Number
County
NON-CUSTODIAL PARENT MUST COMPLETE SECTIONS BELOW:
___________________________________
_____________________
_________________________
Name of Absent Parent
Home Telephone
Work Telephone
____________________________________________________________
_________________________
Address
City
State
Zip
Name of Employer
LIST THE NAME(S) OF YOUR CHILD(REN) YOU PROVIDE SUPPORT FOR:
1.___________________ 2. _______________________ 3._____________________ 4.___________________
I, ______________________________ give ___________________________ the total sum of
Non-custodial Parent
Custodial Parent
$__________________
Check one:
per month
per week
twice a month
every other week
other:___________
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.
I certify that the information I have given is true and factual. I understand that submission of false or misleading
information may result in criminal prosecution.
X___________________________________________________
________________
Signature of Non-Custodial Parent
Date
State of Arkansas, County of ___________________
Subscribed and sworn to me before a Notary Public in and for the county and state aforesaid, this the _____ day
of _______________(mo), __________ (year).
AFFIX SEAL HERE
__________________________________________
Notary Public
My commission expires on _______________, _______(yr).
DCC-576 (7/1/07)
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