Form Csed 04-1017 - Application For Child Support Enforcement Services And Affidavit Of Support Received And Affidavit And Request For Address Confidentiality - Alaska Division Of Child Support Enforcement
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4For office use only: Requested: ___________ Sent: ___________ Case #: ___________________________
Date
Date
Reinstatement/Existing/Other
APPLICATION FOR CHILD SUPPORT ENFORCEMENT SERVICES
Please indicate which Child Support Enforcement Division services you are applying for. You must provide all information
necessary for these services, and you must attach complete copies of existing orders.
Support order establishment
Paternity establishment
Medical support order establishment
Enforcement of an existing order
Review, modification, and enforcement of an existing order
INFORMATION ABOUT YOU (THE APPLICANT)
PLEASE PRINT
Full name________________________________ Birth or previous names used __________________________________
Birthdate _________ Birthplace ______________ SSN ________________ Driver’s license state and # _______________
Mailing address ______________________________________________________ Home phone_____________________
Residence address_______________________________________ Email address __________________________________
Employer______________________________________Work phone _________________ Work hours ________________
Does an attorney represent you in any matters related to the child or the other parent?
Yes
No
If yes, provide the
________________________________________________________________
attorney’s name, address, and phone
Have you ever received public assistance such as ATAP (Alaska Temporary Assistance), TANF (Temporary Aid to Needy
Families), AFDC, or Medicaid?
Yes
No If yes, indicate what type, when, in what state, and provide a case number if
available ____________________________________________________________________________________________
CHILDREN YOU ARE SEEKING SUPPORT FOR
Child’s full name
Sex
Date and place of birth
Social security #
Who does this child live with?
You are the
mother
father
relative __________
legal custodian by court order (explain)______________________.
NONCUSTODIAL PARENT YOU ARE SEEKING SUPPORT FROM
Full name _________________________________________ Birth or previous names used __________________________
Birthdate ____________ Birthplace ________________ SSN _____________ Driver’s license state and # _______________
Address
Current
Last known ________________________________________________________________________
Email address ___________________________ The person is a citizen of
U.S.
another country __________________
How is the person related to the child or children listed above? _________________________________________________
Height _________Weight ________ Hair color ________ Eye color _________ Marks, scars, tattoos________________
Does/did the person live or work in Alaska?
Yes
No If yes, where and when? _________________________________
Usual occupation ____________________________ Union member? (name and local number) _______________________
Current or most recent employer(s)
Employer address
Employer phone
Date of employment
Military:
None
Active
Reserve
Guard
Retired Branch/unit _______ Last rank/grade ______ Yrs in service _____
Tribal or Alaska Native corporation member?
Yes
No
If yes, which?_______________________________________
_____________________
Does this person have an attorney regarding child support?
Yes
No If yes, who?________
Does the person receive or expect any large cash gifts, settlements, or awards? ______________________________________
Other information that may be helpful in obtaining support (bank accounts, stocks, property, pensions, etc): _______________
____________________________________________________________________________________________________
CSED 04-1017 (Rev. 04/05/01) (9 pp.)
Custodian’s Application for Services
Page 2 of 9
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