Parent Responsibility Agreement Of Informal Child Support Form

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P.O. Box 131869
Tyler, TX 75713
1-800-676-8283
EMAIL:
WEBSITE:
Child Care Services
Parent Responsibility Agreement
Child Support & Paternity Verification Form for Informal Child Support
(Child Support is not filed through the OAG or through the Court)
State law requires a family receiving child care assistance to comply with the Parent Responsibility Act. The Parent Responsibility Act includes the
receipt of child support for each individual child in the household under the age of 18. Failure to comply with this requirement will result in
denial or termination of child care services. The Child Support & Paternity Verification Form is provided to assist parents in documenting the
informal child support payment arrangement with the child’s absent parent NOT living in the household.
WHEN TO USE THIS FORM: This form is used ONLY when there is an informal child support agreement with the absent parent(s).
IMPORTANT NOTICE
Informal child support arrangements with different absent parents will require a separate form to be completed for each absent parent. Please
request or make copies of this form for each absent parent to complete and sign. THE ABSENT PARENT SIGNATURE MUST BE NOTARIZED.
PLEASE READ THE FOLLOWING REQUIREMENTS:
a. The minimal monthly child support amount is $100 for the first child and $25 for each additional child of the absent parent. If more than one
absent parent, each is required to meet the minimal amount for his/her child. b. Child support payments falling below the minimum established
amount will result in the denial/termination of child care services. c. A three (3) month history of payments must be documented.
I ______________________________________ am the father/mother of the child/children listed below:
(Print Absent Parent Name)
(Circle one)
Child Name: __________________________ DOB: ____________
Child Name: _________________________ DOB: ___________
Child Name: __________________________ DOB: ____________
Child Name: _________________________ DOB: ___________
I pay _________________________________ $___________
weekly, every two weeks, monthly for support of this child/children.
(Print Custodial Parent Name)
(Circle one)
Absent Parent Physical Address: ________________________________________
Mailing Address: ________________________________
Please list your payment history for the last three (3) months:
Month
Amount of Monthly Financial Support
_________________________
$ __________________
_________________________
$ __________________
_________________________
$ __________________
_____________________________________________________________________
Date: _____________________________
Custodial Parent Signature
_____________________________________________________________________
Date: _____________________________
Absent Parent Signature (must be notarized)
State of ______________________
________________________________________________
County of ____________________
Notary Public’s Signature and Date
_______________________________, personally appeared before me,
and being duly sworn, declared that he/she signed this form in the capacity
(Personalized Seal)
designated and further states he/she has read the above requirements
and the statements therein contained are true.
This is an equal opportunity program. Auxiliary aids and services are available upon request. TX Relay 1-800-735-2989.
CCS Form 004-revised 10/2015

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