Application For Child Support Services
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1APPLICATION FOR CHILD SUPPORT SERVICES
(Existing Dane County Court Case Only)
If you are involved in a family court action in Dane County, and have children, you may use
this form to apply for services from the Dane County Child Support Agency. There is NO APPLICATION FEE
for our services. We can assist you with the following:
Collect court ordered child support through income withholding
Enforce the payment of unpaid support through tax refund intercept, liens, license suspension and
other administrative processes.
You can get more information about the child support program at
If you are interested, please complete and return the application form below and attach a copy of your most
recent court order (if any):
Dane County Child Support Agency
Room 365
210 Martin Luther King Jr. Blvd.
Madison WI 53703
Please note the following regarding Child Support services:
Child support agencies DO NOT handle child custody or physical placement (visitation) issues.
A Child Support attorney who appears at your hearing represents the State of Wisconsin, not you. Applying for services does not
create an attorney-client relationship with the Child Support attorneys.
If you have a percentage–expressed child support order, and you apply for child support services, the agency is required by state
law to ask the Court to change your order to a fixed dollar amount.
If the agency collects support arrears through tax refund intercept and the refund is recalled, you will have to return the p ayment. If
a tax intercept collection is at least $10, a fee of 10%, up to $25, will be deducted from the collection.
______________________________________________________________________________________________
Application for Child Support Services
Applying for:
Child Support Enforcement
Establish Paternity (legal fatherhood)
Health Insurance
Yes, I _____________________________________ want Dane County Child Support Agency services.
(Please print your name clearly)
I
am ordered to
PAY support
RECEIVE support
provide health insurance
PENDING–divorce not finalized
My address: _____________________________________________________________________________
(Street)
(City)
(State)
(Zip)
My Date of Birth: __________________ My Social Security Number: ______________________________
Phone: Home ______________________ Work _________________
Cell __________________________
Dane County Court Case Number ____________________
Health insurance for child(ren)?
Yes
No If yes, insurance company? _______________________
other parent’s policy
Health insurance provided under
my policy
Other Parent: _______________________________________ ________________ ____________________
First
Middle
Last
Birth Date
Social Security Number
(if know n)
(if know n)
Address: _____________________________________________________ Phone #s: _________________
(Street)
(City)
(State)
(Zip)
Other Parent’s Employer: _____________________________________________________
Child(ren) Names, Date of Birth and Social Security Numbers (if known):
__________
___________________________________________________________________________________________________________
________________________________________________________________________________________
Signature: ______________________________________________
Date: ________________________
Updated 4/9/13
DANE
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