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 Page 2
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1
2
3
4RELATIONSHIP BETWEEN THE PARENTS
Divorced
Date________ City/state ______________________ Case number _________
Attach a complete copy of the divorce decree or order.
Married but separated
Marriage date/place ______________________________ Separation date ________
Divorce/Dissolution pending
Date filed
City/State ______________________ Court case number _______
Never married
Complete the following and attach a birth certificate for each child (add pages if needed)
Child: _____________ Did the father sign an Affidavit of Paternity?
Yes
No
Is the father’s name on the birth certificate?
Yes
No
Child: _____________ Did the father sign an Affidavit of Paternity?
Yes
No
Is the father’s name on the birth certificate?
Yes
No
Other (explain) _____________________________________________________________________________________
OTHER INFORMATION
If you have been a victim of domestic violence, check here and submit an “Affidavit and Request for Address
Confidentiality” to ask that your address be kept confidential. (The affidavit form is included in this application package.)
If you have had a child support case in Alaska or another state, check here and explain: In which state/county? __________
For which child/children? ________________________ Do you know the case number? _________________________
If any child is eligible for Indian Health Service, military, or other medical or health coverage, check here and explain:
For which child/children? ________________________ Eligibility is through which parent? ______________________
Type of coverage? __________________________________________________________________________________
Check here if you want to receive support payments by direct deposit. By signing below, you are authorizing the State of
Alaska to make adjustments, if necessary, to your account to correct erroneous
Attach a
deposits. The state will make reasonable efforts to notify you within 24 hours if
voided
adjustments are made. This authority remains in effect as long as you have an
check or
deposit
open child support case or until you cancel this authorization in writing. The
slip here.
name on the child support case must match the name on the account into which
deposits are being made. Thirty days written notice is required to change
accounts. You must notify CSED if you close your account, change your address, or change the name on your account.
Direct deposit can begin only after account information is electronically verified.
Your signature is required before CSED can process this case.
You must include a complete copy of all orders relating to custody, support, or paternity.
You must complete the Affidavit of Support (even if you receive no support) and have it notarized.
You must complete the confidentiality affidavit (page 6) if you want your address kept confidential.
Applicant's signature: ________________________________________
Date: _____________________
Return the completed application (pages 2-4, and page 6 if needed) and all supporting documents to:
Child Support Enforcement Division
th
550 W 7
Avenue Suite 310
Anchorage AK 99501-6699
CSED 04-1017 (Rev. 04/05/01) (9 pp.)
Custodian’s Application for Services
Page 3 of 9
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