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Form Dws-Hcd 884 - Alimony And/or Child Support Form - Department Of Workforce Services - Utah

DWS-HCD 884

State of Utah

Rev. 10/2013

Department of Workforce Services

CHILD SUPPORT – ALIMONY STATEMENT

PAID OR RECEIVED

PART A – PAID OUT CHILD SUPPORT and/or ALIMONY

Child Support

I ____________________ certify that I paid child support in the amount of $_________ for the month and

year of ___________20____. The child support paid was for _______# of children.

Name & address of person receiving child support is:

Name: _________________________________________________________________________________

Address: _______________________________________________________________________________

Alimony

I ____________________ certify that I paid alimony in the amount of $_________ for the month and year of

___________20____.

Name & address of person receiving alimony is:

Name: _________________________________________________________________________________

Address: _______________________________________________________________________________

PART B – RECEIVED CHILD SUPPORT and/or ALIMONY

Child Support

I certify that the total amount of child support that I received for the month and year of ___________20___ is

in the amount of $__________ which was support for ______# of children who are under my care.

The child support was paid to me by _________________________________________________________.

Alimony

I certify that the total amount of alimony that I received for the month and year of __________20___ is in the

amount of $_____________. Although the divorce decree or court may have assigned a different amount, I

certify that I did not receive that amount, and that the above-stated amount is what was actually received.

DECLARATION:

I certify the information provided in this form is true. I am aware that providing false

information to the HEAT program is grounds for denial of my application, and that I may

be required to repay any difference that false information made toward the calculation

of my HEAT benefit.

Client Signature

Date

Equal Opportunity Employer Program

Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals

with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.

Form Dws-Hcd 884 - Alimony And/or Child Support Form - Department Of Workforce Services - Utah