Instruction For Form Csed 04-1605 - Affidavit Of Support Received printable pdf download

Instructions for Completing Affidavit of Support Received

Case Caption:

a. Write the name of the state and the county or judicial district in which you are making this

written statement.

b. Write the CSED case number, if known, and the non-custodial parent’s name.

Introductory statement:

Write your first name, middle initial and last name

Statement # 1:

Write the first name, middle initial, last name and birthdate for each child for

which you are receiving or received child support.

Statement # 2:

Check one of the two sentences that apply to your situation. If you checked the

first sentence, please circle the type of order (administrative or court) in your case.

Statement #3:

Check one or both of the boxes describing the two situations that apply to you.

If you checked only the first box, then you only need to fill in the monthly amount of child

support payments you received from the non-custodial parent. If you also checked the second

box, then you also need to fill in the monthly amount of alimony you received from the non-

custodial parent.

The “overnight visits, alimony and support paid” table:

Write the number of nights the children visited the non-custodial parent for each month under the “Overnight”

column. Under the column headed “Alimony”, please write the amount you received as spousal support for

that month from the non-custodial parent. For the “Support “ column, please write the amount you received as

child support for that month from the non-custodial parent. (DO NOT INCLUDE PAYMENTS RECEIVED BY

THE CHILD(REN) FROM SOCIAL SECURITY.) Begin with the month and year you started receiving child

support and continue monthly through the current month and year. Total each column.

EXAMPLE

The non-custodial parent paid $100 per month in child support beginning January through May and then in September

through November of 1988. The non-custodial parent paid $50 per month for June through August and then for

December. In addition, the non-custodial parent paid $100 for spousal support during the months of January through

March, September and October. Fifty dollars for spousal support was paid for the months of June through August and

November. No spousal support was paid for the months of April, May and December. The child spent two weeks with

the non-custodial parent in January and December, had summer visitation during June through August and weekend

visits for the remaining months.

YEAR __1988__

Overnight

Alimony

Support

JAN

$100.00

FEB

$100.00

MAR

$100.00

APR

0.00

$100.00

MAY

0.00

$100.00

JUN

$50.00

JUL

$50.00

AUG

$50.00

SEP

$100.00

OCT

$100.00

NOV

$50.00

$100.00

DEC

0.00

$50.00

TOTAL

174

$700.00

$1000.00

Do not combine child support amounts and spousal support amounts into one column, please separate the two

amounts. Keep pink copies for your records.

Signature and notary block:

After completing this form, sign as custodian in front of a notary public. The

notary will complete the notary block information and stamp it with a notary seal. If a notary is not available your

local postmaster can notarize your signature.

If you have any questions in completing the attached form or should you need additional forms, please contact

the Child Support Enforcement Division, 550 West 7th Avenue, 3rd Floor, Anchorage, Alaska 99501-6699, or by

calling 907-269-6900 or toll free within Alaska 800-478-3300.

Important! Under Alaska statutes, a false statement of a material fact or lying under oath can lead to a charge of

perjury and may result in fines and criminal penalties.

CSED 04-1605 (Rev8/99)

Instruction For Form Csed 04-1605 - Affidavit Of Support Received

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