Child Support Information - Vermont Department For Children And Families


Child Care Financial Assistance Program
Child Support Information
You have reported that your spouse/partner is no longer in the home and you are separated. Please complete the
information below in order for your child care financial assistance to be re-determined. If you are currently
married or have ever been married, you must provide proof of legal separation at your next re-determination date.
If you are receiving child support, complete the boxes below.
If you receive court ordered child support please submit a 6 - 12 month child support disbursement record.
Court Ordered?
Name of child for whom
Name of absent person
Amount Received
support is received
paying child support
If you are not receiving court ordered child support you must provide a detailed explanation below including the
name and physical address of the second parent. Please indicate how much he/she contributes monthly. If the
contribution is in the form of goods (diapers, wipes, clothing), mortgage payments, rent payments, etc., please
indicate a monthly value in dollars.
Name of Second Parent:
Physical Address of Second Parent:
Monthly Child Support Amount Contributed:
Please Note: If we are unable to verify the physical address of the second parent, additional documentation may be necessary.
• I certify that the information given on this form is true and correct to the best of my knowledge.
• I understand that I could be subjected to prosecution for fraud if I provide incorrect or misleading information
or do not report changes to the above within 10 business days.
• I understand that I am required to report any changes that may affect my eligibility within 10 business days.
Applicant Name (Please Print)
Signature of Applicant
Agency of Human Services
Revised 08/2016


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