Application For Child Support Enforcement Services Page 4
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4School or Training: __________________________________ Degree/Certificate ______________
Vehicle: _________________________________________ Approximate Value $ ______________
Description: Make/Model/Year
Name on Title : ________________________________________________________________
Bank Account: ________________ Name of Financial Institution: ________________________
Checking/Savings
Other Financial Assets: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
V. MARRIAGE AND PATERNITY INFORMATION
Were the parents of the child ever married to each other?
Yes
No
If Yes, Date of Marriage: __________ Place of Marriage: ________________________
City and State
If the parents were never married to each other, did the father sign a Paternity Affidavit?
Yes (
.)
No
We will need a copy of the Paternity Affidavit
If parents were never married to each other, has paternity for this child(ren) already been established by either a
State or Tribal Court?
Yes (
.)
No
We will need a copy of the order
VI. COURT ORDER INFORMATION
If the parents were married, are they now divorced?
Yes
No
If Yes, Date of Divorce: _________________ Place of Divorce: _________________________
City and State
Is there an order that requires the Non-Custodial Parent to pay child support for children?
Yes (
.)
No
We will need a copy of the order
If Yes, Type of Order (Child Support, Divorce, Dissolution, Tribal, Paternity, Temporary, etc.)
Order # ______________ Date Entered: __________ Place Entered: ________________
Amount of Child Support Ordered: $ _______________ Frequency: _______________
Where are the payments made? ___________________________
Have you ever applied for Child Support Services for any of these children in the past?
Yes
No
If Yes, name of the Agency where you applied for services __________________________________
Date you applied for services: __________________
MY UNDERSTANDING
I understand that all the information that I give is, to the best of my knowledge, true and correct and that it may
be used in court.
I agree to tell the Three Affiliated Tribes Division of Child Support Enforcement of any new or changed
information that relates to the information that I have already provided.
I authorize the Three Affiliated Tribes Division of Child Support Enforcement to collect child support on my
behalf.
________________________________________ ______________________________________
PRINT NAME
Relationship to the child (mother, father, guardian, etc.)
________________________________________ __________________________
SIGNATURE
DATE
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