Disabled Veterans Resident Fishing/hunting License Application Form - New Jersey Department Of Environmental Protection Page 4

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NJ Child Support Certification Form
(Required by Child Support Program Improvement Act, N.J.S.A. 2A:17-56.7a, et seq.)
Hunters and anglers are required to complete a Child Support Certification form when
purchasing a NJ hunting, fishing or shellfish license or related permit
Calendar Year 20 ________
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation?
Yes
No
1.) If “Yes”, are you in arrears in payment of said obligation:
Yes
No
2.) If “Yes”, does the arrearage match or exceed the total
amount payable for the past six months?
Yes
No
b. Have you failed to provide any court-ordered health
insurance coverage during the past six months?
Yes
No
c. Have you failed to respond to a subpoena related to either
paternity or child-support proceeding?
Yes
No
d. Are you the subject of a child-support related arrest warrant?
Yes
No
In accordance with N.J.S.A. 2A:17-56, 44d, an answer “yes” to any of the questions 2.) a.
through d. will result in a denial of licensure or certification. Furthermore, any false certification
of the above may subject you to a penalty, including but not limited to, immediate revocation or
suspension of licensure or certification.
Date __________
______________________________ ____________________________
Applicant’s Name (please print)
Applicant’s Signature
Agency Use Only:
License Type ________________________________
Number_____________________________________
*Pursuant to N.J.S.A. 2A 17-56.44e. of the New Jersey Child Support Enforcement Law, the Division of Fish and
Wildlife is required to obtain your Social Security Number. The Division is further obligated to provide your Social
Security Number to the Probation Division or other agency responsible for child support enforcement.

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