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 3
ADVERTISEMENT
1
2
3
4AFFIDAVIT OF SUPPORT RECEIVED
If more than one page is needed, please make copies of this page. See back for instructions.
If you received no support, please submit this affidavit with the “no support received” options checked in Items 3 and 4.
State of _______________________________
CSED case number __________________________________
Noncustodial parent’s name ____________________________
Judicial District/County __________________
I, ______________________, being first duly sworn, do swear under penalty for lying under oath that the following information
is true and accurate to the best of my knowledge:
1.
I am the custodian of these minor children:
Child’s full name
Date of birth
Child’s full name
Date of birth
2.
An administrative order from
A court order directs that I am
No administrative or court
CSED or another child support
OR
entitled to receive
OR
order for child support is in
agency directs that I am entitled
child support
effect at this time.
to receive child support.
alimony
spousal support)
(
3.
I received child support
I am not sure how much child
I have received no child
payments directly from the
OR
support I’ve received from the
support from the noncustodial
OR
noncustodial parent as listed in
noncustodial parent. I estimate that I
parent.
the table below.
received $_________________ in
(year/month) _________________.
4.
I received alimony (spousal
I am not sure how much alimony
I have received no
support) directly from the
OR
(spousal support) I’ve received from
OR
alimony (spousal support)
noncustodial parent as listed in
the noncustodial parent. I estimate
from the noncustodial parent.
the table below.
that I received $ ____________ in
(year/month) _______________.
Year:
Child Support
Alimony/
Year:
Child Support
Alimony/
Year:
Child Support
Alimony/
Spousal
Spousal
Spousal
Jan
Jan
Jan
Feb
Feb
Feb
Mar
Mar
Mar
Apr
Apr
Apr
May
May
May
Jun
Jun
Jun
July
July
July
Aug
Aug
Aug
Sep
Sep
Sep
Oct
Oct
Oct
Nov
Nov
Nov
Dec
Dec
Dec
______________________________________________
Signature of Custodian
CSED main office mailing address:
SUBSCRIBED and SWORN to me this ____day of ______________, 20___
th
550 W 7
Ave Suite 310
Anchorage AK 99501-6699
_______________________________________________
Notary Public for the State of ____________________________
My commission expires: ________________________________
[This page separately available as CSED 04-1606 (Rev. 04/05/01) (1 p.) Affidavit of Support Received]
CSED 04-1017 (Rev. 04/05/01) (9 pp.)
Custodian’s Application for Services
Page 4 of 9
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal