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 4
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4AFFIDAVIT and REQUEST for ADDRESS CONFIDENTIALITY
Complete this affidavit only if you want your address to be kept confidential.
CSED will respond in writing with a decision about your request.
I, ______________________________________________, swear under penalty of perjury that the following information is true to
the best of my knowledge and belief:
1.
Name of noncustodial parent I do not want information released to:
Child Support Enforcement case number (if known):
_____________________________________________________
___________________________________________
2.
The noncustodial parent has committed domestic violence (threatened, harassed, physically or mentally abused, or committed sexual
assault or incest) against me or my children in the following way: Describe who was involved, when, where, and how it happened.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
A domestic violence protective (restraining) order
has
has not been issued against the noncustodial parent. (If yes, please
3.
provide information about the case): Court case number ______________________
Court location ________________________
(Describe who was involved, when, where, and how it happened): _____________________________________________________
__________________________________________________________________________________________________________
The noncustodial parent
has
has not been charged with a crime (such as assault or harassment) or been involved in a civil
4.
or criminal court case in which I was a party, a victim, a witness, or otherwise involved. (If yes, please provide information about the
case): Court case number ______________________
Court location ______________________________ Describe who was
involved, when, where, and how it happened: _____________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
5.
Other information about why I feel threatened by the noncustodial parent, and why I want my address kept confidential: _________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________
____________________________________________________
Signature
Date
SUBSCRIBED and SWORN to before me this _________ day of ______________________________, 20 ______
______________________________________________________________________
Notary Public for the State of ___________________________
My commission expires ________________________________
If you can’t get to a notary, please sign before a witness and have the witness complete the information below.
I acknowledge that I know the person who signed this form is the person he or she claims to be, and that I witnessed the signature above.
Witness’s signature ______________________________________ Witness’s name (please print) _____________________________
Witness’s Social Security number (optional) ___________________ Witness’s phone ______________________________________
Witness’s mailing address________________________________________________________________________________________
th
CSED main office mailing address:
550 W 7
Ave Suite 310
Anchorage AK
99501-6699
[This page separately available as CSED 04-0502 (Rev. 04/05/01) (1 p.) Affidavit and Request for Address Confidentiality]
CSED 04-1017 (Rev. 04/05/01) (9 pp.)
Custodian’s Application for Services
Page 6 of 9
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