Child Support Information - Vermont Department For Children And Families

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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
Yes
No
$
per
$
per
$
per
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.
Explanation:
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
Date
Agency of Human Services
Revised 08/2016

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