Ivd Child Support Services Application Or Referral - State Of Michigan Page 3
Download a blank fillable Ivd Child Support Services Application Or Referral - State Of Michigan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ivd Child Support Services Application Or Referral - State Of Michigan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3E. GENERAL INFORMATION
41. I believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or the child.
Yes
No
42. I have received or I am currently receiving benefits from the Family Independence Program (FIP) or I have received past benefits from Aid to Dependent Children (ADC).
Yes
No
If yes, when?
Where?
43. I have received or I am currently receiving Medicaid (MA).
Yes
No
If yes, when?
Where?
44. I am currently receiving:
Food Assistance Program (FAP)
Yes
No
Child Development and Care (CDC)
Yes
No
F. ACKNOWLEDGEMENT FOR CUSTODIAL PARENTS AND CARETAKERS
The Michigan Office of Child Support (OCS) processes child support payments through the Michigan State Disbursement Unit (MiSDU), which is part of the Michigan Department of Health and Human Services
(MDHHS). The MiSDU receipts and distributes payments by direct deposit to a bank account, to a debit card, or by paper check.
If I am sent money in error or overpaid, the MiSDU will take all the necessary steps to correct errors in the processing of my child support payments. By checking the “yes” box below, I give OCS permission to
withhold an incremental amount specified below from future child support payments owed to me. To revoke my consent, I must notify the Friend of the Court office. Failure to check “yes” has no effect on my
eligibility for IV-D Child Support services through OCS.
Yes, (circle one)
10%
25%
or
50%
Failure to choose a percentage will result in a default amount of 25%.
No, please contact me before you attempt to recover an amount from my support payments.
G. ACKNOWLEDGEMENT FOR ALL APPLICANTS
Authorities:
I request child support services available under Title IV-D of the Social Security Act.
All Services
45 CFR 302.33 Completion: Application is voluntary for non-
assistance applicants.
Locate Only (for custodial parents and caretakers only)
Medical Support Only (for Medicaid cases only)
R 400.3009 MAC and R 400.5008 MAC Failure to complete may result in
loss of benefits from Child Development and Care (CDC) and the Food
I understand that disclosure of my Social Security number is mandated by the Social Security Act, 42 USC 666(a)(13), in order that
Assistance Program (FAP). Current FAP and CDC recipients are not
Michigan’s child support program may provide services related to the establishment of paternity and the establishment, modification
required to sign the form.
and enforcement of child support obligations. I understand that I must cooperate in taking support action to ensure that my child
support case remains open. I declare that the information provided above is true and correct to the best of my knowledge and agree
to report changes in my circumstances that may affect support action in my case.
42 USC 654(29) Failure to provide information may result in loss of
Family Independence Program (FIP) benefits for all family members and
I certify that I have received a copy of DHS Publication 748, “Understanding Child Support, A Handbook for Parents.”
loss of Medicaid (MA) for all adult members.
Applicant’s Signature (Signature is Required)
Date
Return completed application to:
Applicant’s Printed Name
Michigan Office of Child Support
Central Functions Unit
Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race,
P.O. Box 30744
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political
beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
Lansing, MI 48909
make your needs known to an MDHHS office in your area.
This institution is an equal opportunity provider.
DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Genesee County Friend Of The Court - Modification Objection To Child Support Order Recommendation - Seventh Judicial Circuit Of Michigan
Legal
Form 2824 - Application For Replacement Claiming Lost, Destroyed, Undelivered Or Stolen State Of Michigan Ifta Fuel Decal(s) 2009
Financial
Related Categories
Parent category: Legal