La Crosse County Child Support Financial Disclosure Page 2
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2Health Insurance Coverage: Please check the applicable selection
____I am covered under BadgerCare ____I do not have health insurance coverage
currently because:
___I am unemployed
___It is not offered to me because
_______________________________________________________________________
If you have health insurance offered to you by your employer, regardless if you are
currently carrying the coverage, you must include documentation from your
employer outlining the insurance plan premiums for all of the plan types offered (ie:
single, limited family and full family plan) .
Health Insurance
Dental Insurance
Company name:
__________________
_______________________
Cost of single policy*
__________________
_______________________
Cost of family policy*
__________________
_______________________
Policy book available?
_________________
_______________________
Effective date:
__________________
______________________
Covered Persons:
__________________
______________________
__________________
______________________
Income Tax Claim Information:
If the child(ren) have been claimed for income tax purposes in the past, please provide
details about what the arrangement has been.
________________________________________________________________________
________________________________________________________________________
If the child has not been claimed in the past or you would like to request what the claim
arrangement should be, please indicate that here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Providing your Social Security number (SSN) is voluntary. Failure to provide your SSN
may result in an information-processing delay.
Please return the financial disclosure and medical insurance documentation to the
Child Support Agency at least five (5) days from the date received to:
La Crosse County Child Support
333 Vine St. Room 1701
La Crosse, WI 54601
I declare, under penalty of perjury, that the foregoing, including any attachments, is
complete, true and correct.
______________________________
____________________
Signature
Date
Have you remembered to include:
____ 8 weeks of paystubs
____ Last two years of tax returns if self employed or if specifically requested
____ Employer Sponsored Health Insurance Premium Information
____ Military Leave and Earning Statement if Military Personnel
____ Tribal Per Capita Income
12/14/15
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