Fillable Printable Application for Child Support Service - Idaho
Fillable Printable Application for Child Support Service - Idaho
Application for Child Support Service - Idaho
7
Application for Child Support Services
INFORMATION ABOUT THE CUSTODIAL PARENT (the parent or guardian who lives with the child)
1. Name
_____________________________________________________________________________________________________________
First Middle Last
2. Social Security Number _____/_____/______ Sex Female Male
3. Date and place of birth _____/_____/_____ _______________________________________________
Month Day Year Place of Birth
4. Home
Address ______________________________________________________________________________________________________
Street City State ZIP
5. Mailing Address (if different) __________________________________________________________________________________________
Street (or P.O. box) City State ZIP
6. Home Phone ( ) ________________ Work Phone ( ) ________________
7. Have you ever received cash assistance, such as AFDC or TAFI? Yes No
If yes, when and in which state? ________________________________________________________________________________________
8. Have you ever received Medicaid? Yes No If yes, when and in which state?____________________________________________
9. Does an attorney represent you on any matter related to the non-custodial parent? Yes No
If yes, please list the attorney’s name, address, and telephone number:
___________________________________________________________________________________________________________________
Name Street City State ZIP Phone Number
10. What is your relationship to the child? Parent Stepparent Grandparent Sibling Other ______________________________
11. Please list the name of a close friend or relative who always will be able to get in touch with you if we are unable to :
__________________________________________________________________________________________________________________
Name Street City State ZIP Phone Number
INFORMATION ABOUT THE NON-CUSTODIAL PARENT
(the parent who does not live with the child)
12. Name
_____________________________________________________________________________________________________________
First Middle Last
13. Social Security Number _____/_____/______ Sex Female Male
14. Date and place of birth _____/_____/_____ ______________________________________________________________________
Month Day Year Place of Birth
15. Home
Address ______________________________________________________________________________________________________
Street City State ZIP
16. Mailing Address (if different) ___________________________________________________________________________________________
Street (or P.O. box) City State ZIP
Is this address current? Yes No If no, or don’t know, address above was current as of _____/______/_____
Month Day Year
17. Home Phone ( ) ________________ Work Phone ( ) ________________
18. Physical description: Eye Color __________ Hair Color __________ Height __________ Weight _________
Race: Alaskan Eskimo Black White American Indian Hispanic Asian Other _____________________________
Other marks (tattoos, scars, etc.) ______________________________________________________________________________________
19. Who are this person's parents (even if deceased)?
Father’s Name _________________________________________ Mother’s Maiden Name______________________________________
20. Has this person ever been in the military? Yes No If yes, which branch? _______________________________________________
Current status _______________________ Base ________________________________________________________________________
Name City State ZIP
21. Has this person ever been in jail or prison? Yes No If yes, where? ____________________________ When? ________________
22. Is this parent working? Yes No
23. Where does the non-custodial parent work? If you don’t know, list the last known employer:
Company Name ____________________________________________________________________________________________________
Address __________________________________________________________________________________________________________
Street City State ZIP
Phone ( ) ____________________ If employment is not current, when did he/she last work there? _____/______
24. Does this person receive or qualify for SSI SSA/SSD VA benefits Workman’s Compensation Other _______________
25. Other information that may help CSS collect child support, such as other names used, additional employers, or assets this person may have
(bank accounts, automobiles, real property, etc.___________________________________________________________________________
__________________________________________________________________________________________________________________
OFFICE USE ONLY
Date Requested ___________________________
Date Provided ________________________________
Fee Paid __________ Date Received _ ___________
Receipt # ____________ Case # _______________
8
INFORMATION ABOUT YOUR CHILDREN
26. List the following information for each child included in this case. If there is not enough room, list additional children on a separate page.
Name (First, Middle, Last) Sex Date of Birth Social Security Number Placeof Birth
(County and State)
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
27. Has paternity been established for each child? Yes No If not, list children for whom paternity has not been established.
___________________________________________________________________________________________________________________
28. If you are pregnant, when is your baby due? _____/______/_____ Who is the father? _______________________________________
Month Day Year
MEDICAL INSURANCE INFORMATION
29. Who is providing medical insurance coverage for the children in this case? _______________________________________________________
Start date / Effective date: _______________________
___________________________________________________________________________________________________________________
Insurance Company Name Policy # Subscriber #
__________________________________________________________________________________________________________________
Street Address or P.O. Box City State Zip
YOUR LEGAL STATUS WITH THE OTHER PARENT
30. What is your current relationship to the other parent?
Married (Date) _______________ Divorced (Date) _______________ Separated Other ___________________________
31. Is there a divorce decree/support order for any of the children? Yes No If no, skip to question 35.
32. Which county and state set the order?___________________________________________________________________________________
County State
33. What is the court order number? (attach a copy) ______________ Date of your most recent court order ______/______/_____
Month Day Year
34. Amount of monthly current support ordered $_____________ Have any payments been missed? Yes No
If yes, how much past-due support is owed? $_____________ When was the last payment made? _____/______/_____
Month Day Year
REQUESTED SERVICES
35. Please check the service you would like to receive:
All services. This may include establishing paternity, establishing or modifying a support order for financial and medical support, and/or
enforcing the support order.
All services except medical support. Medical support means the non-custodial parent will provide health insurance, if available at a
reasonable cost.
Only services to establish paternity (legal fatherhood.) This will not provide you with child support or medical support services.
Only services to locate the non-custodial parent. This service will provide an address of the other parent only. It will not provide any child
support payments or medical support. The application fee of $25 must be paid before this service will be provided.
Idaho Child Support Services is authorized to endorse and negotiate payments related to child support and spousal support,
including checks, money orders, bank drafts, and electronic payments, on my behalf and on behalf of the children in my case.
I authorize Idaho Child Support Services to take legal and enforcement actions related to my case.
__________________________________________________________________________________________ ________________________________________________
Applicant’s Signature Date
CSS854 2/00
