Fillable Printable Application for Child Support Services - Indiana
Fillable Printable Application for Child Support Services - Indiana
Application for Child Support Services - Indiana
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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES
State Form 34882 (R12 / 1-14) / CSB 425A
Approved by State Board of Accounts, 2014
PRIVACY STATEMENT
*The records in this series are confidential
according to 42 USC 653, 42 USC 654, and 42
USC 663. This agency is requesting disclosure
of personal information for agency purposes as
required by these statutes. Disclosure of this
information is mandatory. Failure to provide
any information may prevent this form from
being processed.
INSTRUCTIONS:
1. Take or mail this completed form to your local county Prosecutor’s IV-D Child Support Office.
2. If multiple other parents, complete one application for each.
NOTICE (please read)
The Indiana Child Support Bureau offers child support services to persons desiring to obtain child support from a parent outside the
home. These services are: Complete Service or Parent Locator Service Only. ALL FEES FOR SERVICES ARE NONREFUNDABLE.
COMPLETE SERVICE: The applicant will be entitled to the Parent Locator Service and the services of the local county Prosecutor’s IV-
D Child Support Office. These services include Establishing Paternity, Establishing and/or Enforcing a support obligation (including
health insurance coverage). The complete service does NOT include handling a divorce case, enforcement of custody or parenting time,
nor matters other than those associated with the support of dependent children. All support payments must be directed to the State of
Indiana for disbursement. ANY COSTS INCURRED IN EXCESS OF THE APPLICATION FEE, SUCH AS COURT COSTS, WITNESS
FEES, GENETIC TEST COSTS, IRS OFFSET FEES AND ADMINISTRATIVE COSTS ASSOCIATED WITH THIS CASE MAY BE
CHARGED AGAINST THE APPLICANT.
In addition, the Tax Refund Offset Project may be used to collect child support arrearages. Application for complete service does not
guarantee that your case will be submitted for tax refund offset nor that tax refund monies will be collected. If any children of the non-
custodial parent have received TANF in the past, any collection made from an offset will first be applied to any unreimbursed public
assistance on any former or current TANF case. If the IRS recalls any portion of an offset refund that has already been paid to you, you
are obligated to repay the State of Indiana the amount recalled by the IRS. You authorize that any such repayment may be deducted
from support collected on your behalf if other arrangements have not been fulfilled.
PARENT LOCATOR SERVICE ONLY: The applicant will be entitled to resources offered by the State and Federal Parent Locator
Service until a verified address is provided or all sources for location are exhausted. The payment of the application fee does not
guarantee a successful location.
TERMINATION OF SERVICES: The applicant may terminate services (if fees, costs and any child support overpayments have been
paid in full) by notifying the local county Prosecutor’s IV-D Child Support Office handling your case in writing that services are no longer
desired. Services may be terminated only in accordance with 45 C.F.R. 303.11.
APPLICANT'S OBLIGATIONS: The applicant is expected to fully cooperate with the local county Prosecutor’s IV-D Child Support Office
in the legal and non-legal preparation of the case, including, but not limited to notifying the local county Prosecutor’s IV-D Child Support
Office of change of address, supplemental information regarding the other parent, reuniting with the other parent, and other information
pertinent to the case.
APPLICANT'S AFFIRMATION
I hereby swear and affirm under the penalties of perjury that the information contained in this application is true and correct to the best of
my knowledge and providing false information could result in perjury charges being filed against me.
I understand that I am to cooperate with the local county Prosecutor’s IV-D Child Support Office in order for my case to be processed, and
non-cooperation can result in termination of services offered by the IV-D agency. I further understand that payment of the application fee
does not guarantee successful action on the case but rather all reasonable attempts will be made in my behalf to obtain successful results
for the service requested. I have read and understand the above NOTICE.
I hereby request the following service under the terms outlined above:
Complete Service Parent Locator Service Only
Type of Services Requested:
Paternity Establishment Support Establishment Support Modification Establishment/Enforcement Health Insurance
Signature of applicant
Date signed (month, day, year)
Application taken by:
Fee paid
$
Case number
FOR OFFICIAL USE ONLY:
Case Type Assigned County of Ownership Special Handling
Applicant Other Parent
Notes/Description
Reset Form
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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)
Part of State Form 34882 (R11 / 12-13) / CSB 425A
Is Applicant under age of eighteen (18)?
Yes No
If yes, Guardian must also complete the “Applicant Guardian Data” section.
APPLICANT DATA
Full name of applicant (last, first and middle initial)
Relationship to dependents on this application (e.g. mother, father, other)
Alias
Maiden
Previous
Nickname
Date of birth (month, day, year)
Gender
Race
Social Security number* / ITIN
Alien Identification number
Is English primary language?
Yes No (If no, please provide.)
Primary language
Interpreter needed?
Yes No
Is special assistance needed?
Yes No (If yes, please specify.)
Specify assistance here (i.e. Physical, Hearing Impaired, Other)
Address of applicant (number and street, rural route number, apartment, or room number, city, state, and ZIP code)
My mailing address is:
Same as above Different (If different, print below including COUNTY.)
Mailing address of applicant (number and street, rural route number, apartment. or room number, city, state, and ZIP code - please include County)
Telephone number (home)
( )
Telephone number (work)
( )
Telephone number (mobile/other)
( )
E-mail address
Preferred Method of Contact:
Personal E-mail/Work/Other E-mail Mobile telephone number Home telephone number Work telephone number Mail
Is there a history of family violence?
Yes No (If yes, complete next box.)
Was a police report filed?
Yes No
Date filed (month, day, year)
City and state filed
Are you party to an active protective order related to the parties on this application?
Yes No (If yes, complete the following boxes.)
County of court order
State of court order
Cause number
Date of court order (month, day, year)
Covered individuals
Are you currently employed?
Yes No (If yes, complete next box.)
Name of employer
Address of employer (number and street, rural route number, apartment, or room number, city, state, and ZIP code)
Military Status
Never Active Reserve Retired
List Military Branch here (Army, Navy, Marines, Air Force or Coast Guard)
Have you previously received Child Support Services from another state or county for the listed Dependents?
Yes No (If yes, complete next box.)
County and State where services were previously received.
Is there an adoption pending for any child listed on this application?
Yes No
Are you requesting child support services for an unborn child?
Yes No
What is the expected due date? (month, day, year)
Are you or any listed Dependents currently receiving Medicaid?
Yes No
Marital status of applicant to other parent
Never married Married Divorce pending Divorced Legally separated Separated
Date of marriage (month, day, year)
Location of marriage (county and state)
Date divorce filed (month, day, year)
Location of divorce filing (county and state)
Date of divorce (month, day, year)
Location of divorce (county and state)
Date legally separated (month, day, year)
Date separated (month, day, year)
Location of separation filing (county and state)
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APPLICANT GUARDIAN DATA
Guardian name of applicant (first, middle, last and suffix)
Relationship to dependents on this application (e.g. mother, father, other)
Guardian address (number and street, rural route number, apartment. or room number, city, state, and ZIP code)
Country (If outside of US, complete the following box.)
International code
Guardian mailing address is:
Same as applicant above Same as above Different (If different, print below.)
Guardian address (number and street, rural route number, apartment. or room number, city, state and ZIP code)
Country (if outside of US, complete the following box)
International code
Telephone number (home)
( )
Telephone number (work)
( )
Telephone number (mobile/other)
( )
E-mail address
DEPENDENT INFORMATION
Last name
First name
Middle name
Suffix
Alias
Nickname
Date of birth (month, day, year)
Gender
Race
Social Security number* / ITIN
Does this child receive SSD or SSI benefits?
Yes No
SSD Amount
SSI Amount
Is the child of this application currently placed in foster care?
Yes No
Was this child born out of wedlock?
Yes No (If yes, then complete the following box.)
Has paternity been established for this child?
Yes No (If yes, then complete the following information.)
How was paternity established?
(If by Court Order, complete the following information.)
Court order Paternity affidavit
Date of court order (month, day, year)
Name of court
County of court
State of court
Court cause number
Do you have a private attorney handling paternity and/or support matters for the child of this application?
Yes No
Name of attorney (first, last, and suffix)
Telephone number of attorney
( )
Do you have a court ordered support obligation for child(ren) listed on the application?
Yes No Unknown (If yes, complete the following information.)
Name of court
County of court
State of court
Court cause number
Is there a court order for custody?
Yes No (If yes, complete the following box.)
Name of person granted custody by court
DEPENDENT INFORMATION
Last name
First name
Middle name
Suffix
Alias
Nickname
Date of birth (month, day, year)
Gender
Race
Social Security number* / ITIN
Does this child receive SSD or SSI benefits?
Yes No
SSD Amount
SSI Amount
Is the child of this application currently placed in foster care?
Yes No
Was this child born out of wedlock?
Yes No (If yes, then complete the following box.)
Has paternity been established for this child?
Yes No (If yes, then complete the following information.)
How was paternity established?
(If by Court Order, complete the following information.)
Court order Paternity affidavit
Date of court order (month, day, year)
Name of court
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DEPENDENT INFORMATION (continued)
County of court
State of court
Court cause number
Do you have a private attorney handling paternity and/or support matters for the child of this application?
Yes No
Name of attorney (first, last, and suffix)
Telephone number of attorney
( )
Do you have a court ordered support obligation for child(ren) listed on the application?
Yes No Unknown (If yes, complete the following information.)
Name of court
County of court
State of court
Court cause number
Is there a court order for custody?
Yes No (If yes, complete the following box.)
Name of person granted custody by court
DEPENDENT INFORMATION
Last name
First name
Middle name
Suffix
Alias
Nickname
Date of birth (month, day, year)
Gender
Race
Social Security number* / ITIN
Does this child receive SSD or SSI benefits?
Yes No
SSD Amount
SSI Amount
Is the child of this application currently placed in foster care?
Yes No
Was this child born out of wedlock?
Yes No (If yes, then complete the following box.)
Has paternity been established for this child?
Yes No (If yes, then complete the following information.)
How was paternity established?
(If by Court Order, complete the following information.)
Court order Paternity affidavit
Date of court order (month, day, year)
Name of court
County of court
State of court
Court cause number
Do you have a private attorney handling paternity and/or support matters for the child of this application?
Yes No
Name of attorney (first, last, and suffix)
Telephone number of attorney
( )
Do you have a court ordered support obligation for child(ren) listed on the application?
Yes No Unknown (If yes, complete the following information.)
Name of court
County of court
State of court
Court cause number
Is there a court order for custody?
Yes No (If yes, complete the following box.)
Name of person granted custody by court
DEPENDENT INFORMATION
Last name
First name
Middle name
Suffix
Alias
Nickname
Date of birth (month, day, year)
Gender
Race
Social Security number* / ITIN
Does this child receive SSD or SSI benefits?
Yes No
SSD Amount
SSI Amount
Is the child of this application currently placed in foster care?
Yes No
Was this child born out of wedlock?
Yes No (If yes, then complete the following box.)
Has paternity been established for this child?
Yes No (If yes, then complete the following information.)
How was paternity established?
(If by Court Order, complete the following information.)
Court order Paternity affidavit
Date of court order (month, day, year)
Name of court
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DEPENDENT INFORMATION (continued)
County of court
State of court
Court cause number
Do you have a private attorney handling paternity and/or support matters for the child of this application?
Yes No
Name of attorney (first, last, and suffix)
Telephone number of attorney
( )
Do you have a court ordered support obligation for child(ren) listed on the application?
Yes No Unknown (If yes, complete the following information.)
Name of court
County of court
State of court
Court cause number
Is there a court order for custody?
Yes No (If yes, complete the following box.)
Name of person granted custody by court
PARTICIPANT INFORMATION FOR OTHER PARENT
Full name of other parent (last, first, middle)
Relationship to Dependents on this application (e.g. Mother, Father, Guardian, Other)
Alias (last, first, middle)
Maiden
Previous
Nickname
Last known mailing address (number and street, PO Box, rural route number, apartment, or room number, city, state and ZIP code - please include County)
Last known street address:
Check here if the same. (If different, complete the information below.)
Mailing address (number and street, rural route number, apartment. or room number, city, state and ZIP code - please include County)
Country (If outside of US, complete the following box.)
International code
Telephone number (home)
( )
Telephone number (work)
( )
Telephone number (mobile/other)
( )
E-mail address
Date of birth (month, day, year)
Approximate age range
Gender
Race
Social Security number* / ITIN
Alien Identification number
Is English primary language?
Yes No (If no, please provide)
Primary language
Interpreter needed?
Yes No
Is special assistance needed?
Yes No (If yes, please specify)
Specify assistance here (i.e. Physical, Hearing Impaired, Other)
Is the other parent currently incarcerated?
Yes No
County of incarceration
State of incarceration
Name of Department of Correction facility
Height
Weight
Hair color
Facial hair
Color of eyes
Glasses
Distinguishing marks / tattoos
Other identifying characteristics
Last known employer
Telephone number of employer
( )
Address of employer (number and street, city, state and ZIP code - please include Country)
International Code
Military Status
Never Active Reserve Retired
List Military Branch here (Army, Navy, Marines, Air Force or Coast Guard)
Deployed Overseas?
Yes No
Is the other parent deceased?
Yes No (If yes, please complete information.)
Date of death (month, day, year)
Place of death (city, county, state, country)
Photo available of other parent?
Yes No
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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)
Part of State Form 34882 (R11 / 12-13) / CSB 425A
TO BE COMPLETED BY COUNTY OFFICE
Application taken by: Date (month, day, year) Application request number
APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES - ASSIGNMENT FOR COLLECTION FOR PERSONS NOT RECEIVING PUBLIC ASSISTANCE
Name of applicant
AGREEMENT (TO BE COMPLETED BY THE APPLICANT)
I understand and agree that support payments collected hereafter from the non-custodial parent named above on behalf of myself and/or the above
named children will be paid to the Department of Child Services, Child Support Bureau, and that said support payments will be paid to me by the agency
after deduction of any charges due and owing to that agency. Such charges are explained on page one of the “Application for Title IV-D Child Support
Services”, executed by the applicant. This authorization shall continue in effect until terminated in the manner set forth on page one of the “Application for
Child Support Services”.
Printed name of applicant
Signature of applicant
X
Date signed (month, day, year)
