Ivd Child Support Services Application Or Referral - State Of Michigan

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IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL
FOR OFFICE USE ONLY
Michigan Department of Health and Human Services
748
Date Requested
Date Provided
Date Filed
Program
Provided
Office of Child Support (OCS)
IV-D Case No.
MDHHS Case No.
County
District
Unit
Worker
Please check your relationship to the children for whom you are applying for child support
services:
Other Caretaker, Specify
Custodial Parent
Non-Custodial Parent or Alleged Father
Custodial Parent - Complete all sections of the form, enter information about you in Section A.
Non-Custodial Parent or Alleged Father – Complete all sections of the form except Section F, enter information about you in Section B.
Other Caretaker - Complete all sections of the form, enter information about you in Section A. Complete information about each parent who is not in the home in Section B.
(Please complete a separate application for each parent who is not in the home.)
A. INFORMATION ABOUT THE CUSTODIAL PARENT/CARETAKER OF THE CHILD
1. Name (First, Middle, Last, Suffix)
2. Birthdate
3. Social Security No.
Maiden Name (If applicable)
4. Home Address (P.O. Box No., No. and Street)
City
State
Zip Code
County
5. Home Phone No.
6. Work Phone No.
7. Cell Phone No.
(
)
(
)
(
)
B. INFORMATION ABOUT THE PARENT WHO IS NOT IN THE HOME
8. Parent’s Name (First, Middle, Last, Suffix)
Maiden Name (If applicable)
9. Social Security No.
10. Birthdate
11. Age
12. Sex (M or F)
13. Home Address (P.O. Box No., No. and Street)
Current
Last Known
City
State
Zip Code
14. Home Phone No.
15. Cell Phone No.
(
)
(
)
16. Weight
17. Height
18. Hair Color
19. Eye Color
22. Car (Make, Model and Year)
20. Birthplace (City, State)
21. Driver’s License Number
23. License Plate Number
24. Race or Ethnic Code:
25. Any Visual Marks or Scars?
Alaskan Native
Hispanic
White
American Indian
Multiracial – More than one racial-ethnic group
Middle Eastern
Asian or Pacific Islander
Black, not of Hispanic origin
Other
26. First Employer Name
Current
Last Known
27. Employer Address (P.O. Box No., No. and Street)
City
State
Zip Code
28. Phone No.
(
)
29. Second Employer Name
Current
Last Known
30. Employer Address (P.O. Box No., No. and Street)
City
State
Zip Code
31. Phone No.
(
)
C. MARITAL STATUS INFORMATION
32a. Has the mother ever married?
b. Name of Spouse
c. Date Married
d. Place (City, County, State)
No
Yes, If Yes>>
33a. Is the mother
b. Date
c. Court Order Exist?
d. Court Order No.
e. Where (City, County, State)
Separated
Legally Separated >>
No
Yes, If Yes>>
34a. Is the mother
b. Date
c. Court Order Exist?
d. Court Order No.
e. Where (City, County, State)
Divorced
Divorce filed >>
No
Yes, If Yes>>
Please attach a copy of all court orders pertaining to the family members listed on this application, including Personal Protection Orders and guardianship papers.
DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word
1

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