Child Support Verification Form
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1
2Child Support Verification Form
School Readiness Program
(Rev. 9.22.17)
If you have a court order for Child Support, please attach proof. Obtain printout and depository number from
Child Support Enforcement office at
Custodial Parent/Guardian Name: __________________________________________________________________________
If you are a Parent/Guardian and do not live with the father/mother of all the child(ren), you are required
to inform us of the status of child support for each absent parent(s) at each placement and
redetermination.
You need to provide proof of the amount of child support for each child counted in the household. Failure
to complete and return this form can result in the loss of your child care funding.
If you do not receive child support and the absent parent(s) has no contact with the child(ren),
•
complete Section I.
If you have contact with the absent parent(s), you must have the absent parent complete
•
Section II.
ABSENT PARENT INFORMATION
Absent Parent Name: ________________________________________________________________________________________
He/She is the Parent of:
(List all children separated by commas) _____________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
Is Child Support Court Ordered? o Yes o No If Yes, what State: _________ Depository #____________________
SECTION I– NONRECEIPT OF CHILD SUPPORT
(To be completed by the Parent/Guardian only if you do not receive child support)
If you are not receiving Child Support, please explain why:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Date of Last Payment Received: __________________
The information provided on this form is true and complete to the best of my knowledge. I fully understand that
any omissions, falsifications or misrepresentations may disqualify my child(ren) from receiving child care funds
and that I may be liable for prosecution under the full strength of the law plus repayment of ineligible child care
services.
____________________________________________________
____________________________________
Custodial Parent/Guardian’s Signature
Date
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Child Support Verification – Rev. 9.22.17 jg
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