Fillable Printable Non-Custodial Parent Application for Child Support Services - South Carolina

Non-Custodial Parent Application for Child Support Services - South Carolina

DSS Form 27103 (JUL 11) Edition of MAR 08 is obsolete.

South Carolina Department of Social Services

NON-CUSTODIAL PARENT’S APPLICATION FOR CHILD SUPPORT SERVICES

(PLEASE READ INSTRUCTIONS BELOW)

Date Application Requested:

Date Application Mailed:

Date Application Received:

InstructIons for Completing the Application

The South Carolina Department of Social Services, Child Support Enforcement Division (CSED), offers to

Non-Custodial Parents (NCPs) the services of “Reviewing of the Child Support Order” and “Establishing

Paternity” for the child or children in question. It is important that you carefully read the entire application and

complete it to the best of your ability. If the application is not fully completed, we will return it to you for completion.

Information about the Custodial Parent (CP) is completed at the bottom of this page. Information about yourself is

completed on pages 2 and 3. Information about the child or children is completed on page 4. Please be sure to read

and detach Part II, “What to Expect,” and keep it for your records.

NOTE: If you are requesting a review of your support order, please be advised that we will review your order

and tell you if you would be entitled to a reduction. However, we will not take legal action to obtain a

reduction for you. Once the review is completed, your file will be closed and you will need to contact a private

attorney to pursue the modification.

To obtain services, mail the completed application and a money order or cashiers check in the amount of $25.00,

made payable to South Carolina Department of Social Services, to:

South Carolina Department of Social Services

Child Support Enforcement Division

P.O. Box 810

Columbia, South Carolina 29202

I am requesting: n Review of Child Support Order n Establish Paternity Only

Under the penalty of perjury I declare that the information given in this application is true and complete to the best

of my knowledge and belief. I have read Part II, “What to Expect,” and agree to the conditions of this application.

Applicant’s Signature: Date:

PART I

Custodial Parent Information

(Person with whom child or children is/are living)

Name: Last: First: Middle: Suffix:

Maiden Name: SSN: Race: Sex: Current Marital Status:

Place of Birth: City: State: Birthdate:

Residential Address: Home Telephone: Cell Phone:

City: State: Zip Code:

Mailing Address: c/o Last: First: Middle: Suffix:

Address: City: State: Zip Code:

Employer’s Name: Work Telephone:

Address: City: State: Zip Code:

Work Start Time: Work End Time:

If Currently Married, Spouse’s Name/Address:

Place of Marriage: City: State: Date of Marriage:

If not currently married, has he/she ever been married? n Yes n No If yes, provide:

Name of Former Spouse: Date and Place of Marriage:

If Divorced, Date and Place of Divorce:

The disclosure of your Social Security Number is mandatory, in accordance

with section 466(a)(13) of the Social Security Act. Social Security Numbers

are used by the South Carolina Child Support Enforcement program to assist in

locating individuals for the purposes of establishing paternity and establishing,

modifying and enforcing child support obligations.

Non-Custodial Parent Information

(Your information)

Name: Last: First: Middle: Suffix:

Sex: Race: SSN: Date of Birth:

Place of Birth: City: State: Alias:

Nickname: Maiden Name: Driver’s License Number:

Driver’s License Date: Driver’s License State:

Current Marital Status: If Married, Your Spouse’s Name:

Last School Attended by You:

Address: City: State: Date:

Current Address: City: State: Zip Code:

Home Telephone: Cell Phone:

Give directions to and a description of your home:

Mailing Address: c/o Last: First: Middle: Suffix:

Address: City: State: Zip Code:

Please furnish the following information on your current or last employer:

Type of Employment: Are you currently employed? n Yes n No

Employer’s Name: Work Telephone:

Employer’s Address: City: State: Zip Code:

Date You Last Worked: What is your monthly salary? $ Shift Worked:

Usual Occupation: Other Skills:

Please list the names and addresses of any other past employers:

Name: Address: Date Last Worked:

What are the names of your parents? (Please indicate their names even if they are deceased.)

Father: Mother:

Last/Suffix/First/Middle Maiden Name/Last/First/Middle

Street or P.O. Box Street or P.O. Box

City/State/Zip Code City/State/Zip Code

Telephone Telephone

DSS Form 27103 (JUL 11) PAGE 2

DSS Form 27103 (JUL 11) PAGE 3

Your Height: Feet Inches Weight: Lbs. Hair Color: Eye Color:

Identifying Mark/Scars: Do you have a police record? n Yes n No

Arrest Date: Offense:

Arrest City: State: Zip Code:

Incarceration Date: Release Date: Incarceration Location:

Incarceration City: State: Zip Code:

Armed Forces Status: VA Service Number: Armed Forces Branch:

A- Active R-Retired D-Discharged

N-Never In U-Unknown

Armed Forces Entry Date: Armed Forces Discharge Date:

Do you have income other than employment income? n Yes n No

If yes, source of income: Amount:

Amount:

Do you have any bank accounts/assets? n Yes n No n Unknown

Name of Bank: Account Number: Type:

Assets:

Do you own any property (real estate, car, etc)? n Yes n No n Unknown

Please list type and location:

What is the name of the insurer with whom you have medical insurance coverage?

Carrier Name: Type of Insurance: Policy Number:

Case Information

Do you have an attorney actively seeking to establish paternity or support? n Yes n No

If yes, attorney’s name:

Do you have a previous court order established? n Yes n No If yes, provide support order number:

(Please attach a copy of the court order)

Name of Court: City: State:

Amount of Support: If you do not have a court order, do you pay voluntarily? n Yes n No

Frequency of Support: Date Last Payment Paid:

B-Biweekly S-Semimonthly M-Monthly W-Weekly D-Seasonal

Support Method: D-Direct to CP C-Through the Court Effective Date of Support Order:

Are you willing to submit to a paternity test? n Yes n No To pay the cost of such test? n Yes n No

Comments:

(Checking/Savings)

DSS Form 27103 (JUL 11) PAGE 4

Child Information

(Complete a separate section for each child)

Child’s Name: Last: First: Middle: Suffix:

Sex: Race: SSN: Date of Birth: Place of Birth:

Has paternity been established for this child? n Yes n No What is your relationship to this child?

In which state did the mother become pregnant? When did she get pregnant?

Were the parents married at the time of the child’s birth? n Yes n No If no, describe the relationship:

If Married: Date of Marriage: Place: If Divorced: Date: Place:

(Month/Day/Year)

Child Information

(Complete a separate section for each child)

Child’s Name: Last: First: Middle: Suffix:

Sex: Race: SSN: Date of Birth: Place of Birth:

Has paternity been established for this child? n Yes n No What is your relationship to this child?

In what state did the mother become pregnant? When did she get pregnant?

Were the parents married at the time of the child’s birth? n Yes n No If no, describe the relationship:

If Married: Date of Marriage: Place: If Divorced: Date: Place:

(Month/Date/Year)

Child Information

(Complete a separate section for each child)

Child’s Name: Last: First: Middle: Suffix:

Sex: Race: SSN: Date of Birth: Place of Birth:

Has paternity been established for this child? n Yes n No What is your relationship to this child?

In what state did the mother become pregnant? When did she get pregnant?

Were the parents married at the time of the child’s birth? n Yes n No If no, describe the relationship:

If Married: Date of Marriage: Place: If Divorced: Date: Place:

(Month/Date/Year)

Child Information

(Complete a separate section for each child)

Child’s Name: Last: First: Middle: Suffix:

Sex: Race: SSN: Date of Birth: Place of Birth:

Has paternity been established for this child? n Yes n No What is your relationship to this child?

In what state did the mother become pregnant? When did she get pregnant?

Were the parents married at the time of the child’s birth? n Yes n No If no, describe the relationship:

If Married: Date of Marriage: Place: If Divorced: Date: Place:

(Month/Date/Year)

DSS Form 27103 (JUL 11) PAGE 5

PART II

What to Expect

(Please read this page and the next carefully and DETACH for your records.)

The South Carolina Department of Social Services (DSS) provides child support services to Custodial Parents

(guardians) and Non-Custodial Parents through its Child Support Enforcement Division (CSED). You must

complete the application to open a case with the CSED.

All cases accepted by the CSED are handled on a first come, first served basis. Claims for visitation, custody

or other issues that are often associated with child support are not handled by CSED.

You must complete this application as thoroughly and accurately as possible and return it to the address

indicated so that the CSED may determine your eligibility for child support services. When completing the

application you may not know the answer to all of the questions, but you should provide as much accurate

information as possible. Please double check any information about which you are not certain. The more

accurate the information you provide, the faster and more efficiently CSED can process your case.

South Carolina law requires that you notify the CSED in writing when you move, change your name, change

jobs or change your telephone number (at home or at work) so that staff will be able to contact you without

delay. You must notify the CSED of these changes within 10 days of the change. If you do not notify the

CSED as required, the court or the CSED may take actions on your case without your knowledge.

If you do not have a court order for paternity, the regional office staff may bring legal action to obtain such a

court order. The regional office will notify you in writing of any court hearings that you must attend.

Please understand that we need your full cooperation throughout this entire process. Your failure to cooperate

could result in CSED closing the case. Before CSED takes any action to close a case, we will send you a

letter indicating what will be required to avoid case closure. You may also close your case at any time by

mailing to CSED a written statement requesting case closure. As a state agency operating under state law

and federal law, legal requirements and policies may conflict with what you request. If a conflict of interest

arises, CSED staff will contact you to discuss the situation.

You are protected by Title VI of the Civil Rights Act and can make written complaints to the Director, South

Carolina Department of Social Services, P.O. Box 1520, Columbia, South Carolina 29202-1520, within 180

days, if at any time you believe you are denied services or otherwise discriminated against because of race,

color, creed, sex, religion or national origin.

Listed below are the telephone numbers of CSED offices.

Thank you for your cooperation. The Department of Social Services pledges to make every effort to help you

obtain the child support owed to your family.

Central Inquiry: (803) 898-9210/1-800-768-5858 Financial Services: (803) 898-9210/1-800-768-6779

Columbia Regional Office: (803) 898-9282 Florence Regional Office: (843) 661-4750

Charleston Regional Office: (843) 953-9700 Greenville Regional Office: (864) 282-4650

Tax Intercept Unit: (803) 898-9314/1-800-922-0852 or 1-888-454-5360

Additional information can be found on our website at: www.state.sc.us/dss/csed/index.html