Fillable Printable Child Support Enforcement Form - Arkansas

Child Support Enforcement Form - Arkansas

Questionnaire and Application

R1015

Office of Child

Support Enforcement

Questionnaire

This Questionnaire is necessary in order to provide child support services. Fill out the questionnaire

completely. The more information we have, the better we are able to help you.

The disclosure of your Social Security number is mandated by Public Law 104-193 in order that the

Office of Child Support Enforcement (OCSE) may provide services related to the establishment of

paternity and the establishment, modification, and enforcement of child and/or medical support

obligations.

If you receive TEA or Medicaid benefits for yourself, including the Arkansas Health Care Independence

Program (also called the Private Option), complete and return only this questionnaire. All other persons

seeking child support enforcement services must return both this Questionnaire and the Contract for

Services. A $25.00 application fee is required from all applicants except those who receive TEA benefits,

Medicaid, including the Arkansas Health Care Independence Program, or whose child is receiving

ARKids 1st A or B. You may return these forms to the local child support office nearest you or mail it to

OCSE, P.O. Box 8133, Little Rock, AR 72203.

Be sure to attach the following:

• Copies of the original child support order, if there was one, and any modified (changed) orders. Also

include copies of any guardianship or custody orders, juvenile orders, temporary orders, probate

orders, or orders of adoption.

• Payment records from the clerk of court or a child support agency in another state.

• Copies of the child’s or children’s birth certificates and an Acknowledgement of Paternity, if one was

signed.

• If you are enrolled in Medicaid or your child is receiving ARKids 1st A or B, provide a copy of your

Medicaid or ARKids card. If you are enrolled in the Arkansas Health Care Independence Program,

provide a copy of your DHS acceptance letter.

Office Use Only

Date Requested: _______________________________

Date Provided: ________________________________

Fee Paid: ________ Date Received: ______________

Receipt #: _______ Case ID: ____________________

Information About You

Name

Physical Address

City, State, Zip

Mailing Address

City, State, Zip

Phone Home Work Cell

Social Security Number Date of Birth

Employer Name

Page 1 of 7

You can complete this form by

hand or online. Once complete,

print the form, sign where

required, and submit to the

appropriate child support office.

Questionnaire and Application

R1015

Employer Address

City, State, Zip

Employer Phone Number

Race: ___Caucasian ___ African American ___ Hispanic ___ Asian

___ American Indian: Tribe ______________ ___ Other: ____________________

Are you or the children under an order of protection? ___Yes ___No

If yes, please provide a copy of the order.

Are you currently receiving the following services?

SSI: ___Yes ___No

SSA/SSD: ___Yes ___No

VA Benefits: ___ Yes ___ No

Worker’s Compensation: ___Yes ____No

Do you receive for yourself and/or the children listed any of the following?

TEA: ___Yes ___No If yes, provide your TEA case number _____________________

Medicaid, including the Arkansas Health Care Independence Program: ___Yes ___No

If yes, provide your case number _____________________

ARKids 1

A or B: ___Yes ___No If yes, provide the ARKids case number ________________

Have you ever in the past received cash public assistance (also known as TEA or TANF)? ___Yes ___No

If yes, please provide the state or tribal name(s) and the time frame during which assistance was received.

State or tribe: _________________________ Years of assistance: from _____ to _____

Do you have an attorney representing you on any matter related to the other parent? ___Yes ___No

If yes, please provide the following information about the attorney:

Name: _______________________________________________

Address: ______________________________________________

Phone number: _________________________________________

Information About The Children

Please provide the following information for each child for whom you are seeking services.

Child 1: Full legal name (first, middle, last) Date of birth Sex

Social Security number Race Place of birth (county & state)

Has a support order been established for this child? Was a Paternity Acknowledgment

completed?

Child 2: Full legal name (first, middle, last) Date of birth Sex

Social Security number Race Place of birth (county & state)

Has a support order been established for this child? Was a Paternity Acknowledgment

completed?

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Questionnaire and Application

R1015

Child 3: Full legal name (first, middle, last) Date of birth Sex

Social Security number Race Place of birth (county & state)

Has a support order been established for this child? Was a Paternity Acknowledgment

completed?

Child 4: Full legal name (first, middle, last) Date of birth Sex

Social Security number Race Place of birth (county & state)

Has a support order been established for this child? Was a Paternity Acknowledgment

completed?

Child 5: Full legal name (first, middle, last) Date of birth Sex

Social Security number Race Place of birth (county & state)

Has a support order been established for this child? Was a Paternity Acknowledgment

completed?

Is the noncustodial parent ordered by a court order to pay child support? ___ Yes ___ No

If yes, which court (county & state/tribe/country)? _________________________________________

What is the court-ordered amount? _____________________________________________________

What is the payment schedule (weekly, monthly, bi-monthly)? ________________________________

Amount of back support owed: ____________________ as of _____________________ (date)

Date and amount of last payment: ______________________________________________________

Was spousal support/alimony ordered? ___ Yes ___ No

If so, do you want OCSE to collect on that obligation: ____ Yes ____ No

If you are the biological parent of the child or children for whom you are requesting services, provide the

following information:

Are you currently or have you ever been married? ___ Yes ___ No

If yes, please provide the following information:

Name of current spouse: ____________________________________ Date of marriage: ________________

Name of past spouse(s): _____________________________________ Date(s) of marriage: ______________

Dates of divorce: __________________________________________________________________________

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Questionnaire and Application

R1015

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Information About The Noncustodial Parent

You may or may not know the following information about the noncustodial parent. Please provide

information to the best of your ability.

Full Name

Alias or Nicknames

Physical Address

City, State, Zip

Mailing Address

City, State, Zip

Phone Home Work Cell

Social Security Number Date of Birth or Approximate Age

Employer Name

Address

Please provide the following information about your legal relationship to the noncustodial parent:

___ Never married to each other

___ Married on __________(date) in ______________________________(state & county/tribe/country)

___ Legally separated on _______________ (date) in _________________(state & county/tribe/country)

___ Divorced on ______________ (date) in _________________________(state & county/tribe/country)

___ Divorce pending in ___________________________ (state & county/tribe/country)

___ Other ____________________________________________________________________________

If you are not the biological parent of the child or children for whom you are requesting service, please

answer the following:

How are you related to the child? _________________________________________________________

What are the names of the biological mother and father of the child? ____________________________

Do you have a court order declaring you as the child’s legal guardian? ____ Yes ____ No

Was the mother married at the time the child was born? ___ Yes ___ No ____ Don’t know

Information About Medical Coverage

Does the child or children for whom you are requesting services currently receive medical coverage other than

ARKids 1st? ___ Yes ___ No (if no, continue to the section Information About the Noncustodial Parent)

If yes, please provide the following information:

Name of insurance company: ______________________________________________

Address, city and zip: ____________________________________________________

Policy number: _________________________________________________________

Subscriber/member number: ______________________________________________

Who provides the insurance? ___ Myself ___ Noncustodial parent ___ Step-parent

___ Other, please explain: ________________________________________________

Does the child receive secondary medical coverage? ___ Yes ___ No

Please explain: _________________________________________________________

Is health insurance available through your employer? ___ Yes ___ No

I prefer to have the responsibility to provide medical coverage for the children listed above. ___Yes ___No

Questionnaire and Application

R1015

Page 5 of 7

City, State, Zip

Physical Description of the other parent:

Eye Color ________ Hair Color ___________ Height _________ Weight ________

Marks (tattoos, scars, piercings, etc.) ___________________________________

Race: ___Caucasian ___ African American ___ Hispanic ___ Asian

___ American Indian: Tribe ______________ ___ Other: ____________________

What are the names of the mother and father of the noncustodial parent, even if they are deceased?

Father’s full name: ______________________________________________________________________

Mother’s full name, including maiden name if known: __________________________________________

Does the noncustodial parent currently receive any of the following:

SSI? ___Yes ___No ___Not Known SSA/SSD? ___Yes ___No ___Not Known

VA Benefits? ___Yes ___No ___Not Known TEA? ___Yes ___No ___Not Known

Worker’s Compensation ? ___Yes ___No ___Not Known

Has the noncustodial parent ever been in the military?

___Yes ___No ___Not Known

If yes, what branch?__________________________

Has the noncustodial parent ever been in jail or

prison? ___Yes ___No ___Not Known

If yes, where? ______________________________

Does the noncustodial parent own a car? ___Yes ___No ___Not Known

Year _____ Make/Model ______________________ License Number _____________ State _______

If the noncustodial parent is currently unemployed, please provide the information for the last known

employer to the best of your knowledge:

Company name: ___________________________ Phone: __________________________

Address: _____________________________________________________________________

Is the noncustodial parent currently married? ___Yes ___No ___Not Known

If yes, list name of the current spouse: _______________________________

Is the other parent represented by an attorney? ___Yes ___No ___ Not Known

If yes, please provide the following information about the attorney:

Name: ____________________________________ Phone: _____________________

Address: _____________________________________________________________________

Where did the noncustodial parent attend high school? _______________________________

How did you and the noncustodial parent meet? _____________________________________

Please list any other information that you feel will help OCSE in working your case. For example: professional,

business, or a commercial driver’s license; other names he or she may use; address where his or her parents

reside; name of any other children the noncustodial parent may have.

How did you learn about our services? (Check all that apply)

__ Another state agency

__ Brochure

__ Child Care referral

__ Educational presentation

__ Expos and fairs

__ I am re-opening my case

__ Internet

__ Letter from OCSE

__ Newspaper /print ad

__ Radio

__ Referred by someone

__ Other-please explain __________

Signature ________________________________________ Date ________________

Questionnaire and Application

R1015

*** NOTICE ***

IF YOU ARE A RECIPIENT OF CASH ASSISTANCE, SUCH AS TEA, OR RECEIVE

MEDICAID, INCLUDING THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM

(ALSO CALLED THE PRIVATE OPTION) FOR YOURSELF, DO NOT SIGN THIS

APPLICATION AND CONTRACT FOR CHILD SUPPORT SERVICES

Application and Contract for Child Support Services

The applicant hereby and herein:

1. Authorizes the agency to assign legal counsel of its choice to act on behalf of the agency and

applicant’s assigned interest, and be the attorney of record for the agency to establish paternity

and/or a monthly support obligation, and to enforce payment of such obligation. The attorney

does not represent the applicant. There is no attorney/client relationship created between the

applicant and the attorney.

2. Understands that the OCSE attorney represents the State’s interest in having children ad-

equately supported and in collecting overdue support. The applicant retains the right to employ

separate private counsel.

3. Agrees that the agency shall have the right to collect from the noncustodial party both current

and past due support payments in the amount provided by the support order.

4. Agrees that the agency, rather than the applicant, shall have any and all rights, title and inter-

est in any and all property belonging to the noncustodial parent against which a claim may be

placed for the collection of child/spousal support.

5. Agrees to forward to OCSE any and all support payments which he or she receives directly

from the noncustodial parent after the date of acceptance of this Application and Contract.

6. Agrees to notify OCSE of any changes in the applicant’s address.

7. Agrees to notify OCSE of any Court action which may change or affect the support order.

8. Agrees to notify OCSE of changes to medical coverage, such as participation in ARKids 1st or

Medicaid, including the Arkansas Health Care Independence Program.

9. Agrees that the agency retains all rights to enforce and collect child support arrearages and

child support judgments in an amount equal to any unreimbursed Transitional Employment As-

sistance (TEA) grant which the applicant received prior to this Contract. Should this contract be

cancelled or terminated, the applicant understands and agrees that OCSE will continue to pursue

the collection of TEA grant through IRS tax intercept until the debt owed to the State is satisfied.

10. Agrees to pay all costs and fees charged for child support enforcement services pursuant to

the Cost Schedule except while participating in ARKids 1st A or B or if receiving public benefits

such as TEA or Medicaid in the future. A copy of the cost schedule for services was provided to

the applicant with this Application and Contract for Services and is incorporated herein by refer-

ence. The applicant understands costs and fees will be deducted from support collected at a rate

not to exceed 13% of the total amount collected or the actual fees and costs due, whichever is

less. The applicant understands that in interstate cases the responding state may charge addi-

tional costs. The applicant further understands that if enrollment in ARKids 1st A or B ceases, the

applicant agrees to pay all costs and fees charged for child support enforcement services pursu-

ant to the cost Schedule for Services that was provided to the applicant with this Application and

Contract for Services but not previously imposed due to their participation in ARKids 1st A or B.

11. Understands the agency will disburse support payments electronically to a prepaid debit card

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Questionnaire and Application

R1015

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unless the applicant requests payment to be made by direct deposit or is granted an exemption.

12. Acknowledges that if situations occur where money is received to which the applicant is not

entitled, the money must be returned voluntarily to OCSE, or, as required by Arkansas law, OCSE

will take the appropriate actions necessary to recover that money. Any decision made regarding

the method of recovery of the money will not preclude or affect child support services being

provided to you by OCSE.

The agency herein:

1. Agrees to provide assistance in establishing a support obligation and paternity if needed, and/

or collecting support on behalf of the applicant’s minor children in such amount as is, or may be,

provided for by a support order.

2. Agrees to assign legal counsel for establishment, collection and enforcement of child support

(including paternity establishment), and medical insurance premiums. The agency undertakes no

representation of the applicant on custody, visitation or any other legal issues.

3. Agrees that the applicant retains the right to hire private counsel to represent his/her inter-

ests in any issue.

4. Agrees to exercise reasonable effort to establish an obligation and to make collections of child

support on behalf of the applicant’s children and spousal support on behalf of applicant, if includ-

ed in an existing child support order.

5. Agrees to post and disburse, within two business days of identification, amounts collected on

behalf of the applicant less the deduction for costs as specified herein. EXCEPTION: Interceptions

from bank accounts and insurance lump sums will be held for 10 days before disbursing. Federal

tax disbursements may be delayed up to six months if the refund is subject to adjustment from

the IRS.

_______________________________________________

Signature of Applicant for Services

_______________________________________________

Date