Application for Child Support Services - Chickasaw Nation

Application for Child Support Services - Chickasaw Nation

Bill Anoatubby The Chickasaw Nation Governor Department of Family Services Family Support Division Child Support Services P.O. Box 1809 / 1301 Hopp...

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Bill Anoatubby

The Chickasaw Nation

Governor

Department of Family Services Family Support Division Child Support Services P.O. Box 1809 / 1301 Hoppe Boulevard / Ada, OK 74821 / (866) 431-3419 / Fax: (580) 272-5512

Dear Applicant: We appreciate the opportunity to assist you and your children. Please maintain this page for your records and read carefully. Attached is the application necessary to initiate child support services with the Chickasaw Nation Child Support Services (CNCSS) program. Please complete the application and attach all of the documentation requested and mail to: P.O. Box 1809, Ada Oklahoma 74821-1809. Please provide the following documentation with your application:   

Your child(ren)’s birth certificate issued by the state CDIB card for you and your child(ren). Social Security cards for you and your child(ren), if possible.

FAILURE TO SUBMIT DOCUMENTATION WILL RESULT IN A DELAY OF OPENING YOUR CASE. IMPORTANT INFORMATION: Please read Section VIII: STATEMENT OF UNDERSTANDING carefully. If you have any questions, please contact the CNCSS office prior to signing the application in front of a notary public. You may locate a notary public at any local child support office, court clerk’s office or local bank. Please understand that the rules and regulations of 25 CFR, the court rules of the Court of Indian Offenses, district state court or tribal court can apply to your case. You have the option to hire an attorney at your own expense, but please be aware that at the time of obtaining a private attorney, our office will no longer correspond with you directly; ONLY your attorney will contact the CNCSS attorney directly. Sincerely,

The Staff of the Chickasaw Nation Child Support Services

Page 1 of 8

Form no. 06579 FS-CSS Rev. 6/2017

The Chickasaw Nation

Bill Anoatubby Governor

Department of Family Services Family Support Division Child Support Services P.O. Box 1809 / 1301 Hoppe Boulevard / Ada, OK 74821 / (866) 431-3419 / Fax: (580) 272-5512

APPLICATION FOR CHILD SUPPORT SERVICES OFFICE USE ONLY: Date requested: ________________ Date received: _______________ FGN: ___________________________ PLEASE PRINT WITH BLUE OR BLACK INK Please mark, if applicable:  Other agency working my child support. What agency (i.e. support kids; state of OK, etc.): _____________________________________________________________________________________________ I.

CUSTODIAL PARENT: This section is about the person with whom the child(ren) actually lives. Middle First Full legal name: Maiden/alias name Last Date of birth:

Social Security number:

Race:

If Native American, what tribe?

 Male

Sex:

What is the relationship of the child(ren) to the custodial parent?

 Female

Who has legal custody?

Mailing address:

City

State

ZIP

Physical address:

City

State

ZIP

County of residence:

Home phone number:

Cell / other phone:

LIST BELOW ALL PRESENT AND PAST EMPLOYMENT, beginning with the most recent and working back for the past five years. You should list all full-time work, part-time work, military service, self-employment, other paid work, student and all periods of unemployment. The entire five-year period must be accounted for without breaks. Name of company and Address (city/state) From To Occupation Hours Hourly phone number mo/yr mo/yr per income week

DOMESTIC VIOLENCE INFORMATION Have you or the child(ren) of this application experience any type of abuse from the non-custodial parent?  Yes  No Type:  Physical  Verbal  Sexual Has the non-custodial parent had a protective order against him/her?  Yes

 No

If yes, please provide a copy. Do you believe that you or the child(ren) may be at risk of emotional or physical harm if the other parent knows where to find you?  Yes  No Page 2 of 8

Form no. 06579 FS-CSS Rev. 6/2017

II.

NON-CUSTODIAL PARENT INFORMATION: This section is about the person who DOES NOT have custody of the children.

A. INFORMATION ABOUT THE FATHER or the person who may be the father of the child(ren), if not the custodial parent. Middle Last First Full legal name: Alias name Date of birth:

Place of birth (city, state):

Race:

If Native American, what tribe?

Home address:

City

Social Security number:

State

ZIP

Home phone number:

LIST BELOW ANY EMPLOYMENT, for the father beginning with the most recent. Name of company and Address (city/state) From To Occupation phone number mo/yr mo/yr

Hours per week

Hourly income

B. INFORMATION ABOUT THE MOTHER, if not the custodial parent. Middle First Last Full legal name: Maiden/alias name Date of birth:

Place of birth (city, state):

Race:

If Native American, what tribe?

Home address:

City

Social Security number:

State

ZIP

Home phone number: LIST BELOW ANY EMPLOYMENT, for the mother beginning with the most recent. Name of company and Address (city/state) From To Occupation phone number mo/yr mo/yr

Page 3 of 8

Hours per week

Hourly income

Form no. 06579 FS-CSS Rev. 6/2017

III. INFORMATION ABOUT THE CHILD(REN). Please list only children with the same mother and father. Last Middle First Social Security number: Full legal name of child: Date of birth: Sex:

City of birth: Race:

Does this child live with you?  Yes  No School address: City

State of birth:

If Native American, what Is child enrolled w/or eligible for Has CDIB been issued? tribe? enrollment?  Yes  No  Yes  No If the child is 18, is he/she currently in Name of school: high school?  Yes  No Graduation year: State Zip code

Is this child receiving TANF, Medicaid and/or medical benefits?  Yes Will the father name anyone else as a possible father?  Yes  No Full legal name of child: Date of birth: Sex:

First

If yes, who?

Does this child live with you?  Yes  No School address: City

Sex:

First

Middle

Does this child live with you?  Yes  No School address: City

Sex:

Does this child live with you?  Yes  No School address: City

Social Security number:

If Native American, what Is child enrolled w/or eligible for Has CDIB been issued? tribe? enrollment?  Yes  No  Yes  No If the child is 18, is he/she currently in Name of school: high school?  Yes  No Graduation year: State ZIP

First

Middle

 No

If yes, who?

If yes, where:

Last name

Last

City of birth: Race:

First name

State of birth:

Will the father name anyone else as a possible father?  Yes  No

Date of birth:

If yes, where:

Last name

Last

Is this child receiving TANF, Medicaid and/or medical benefits?  Yes

Full legal name of child:

 No

If yes, who?

City of birth: Race:

Social Security number:

If Native American, what Is child enrolled w/or eligible for Has CDIB been issued? tribe? enrollment?  Yes  No  Yes  No If the child is 18, is he/she currently in Name of school: high school?  Yes  No Graduation year: State ZIP

Will the father name anyone else as a possible father?  Yes  No

Date of birth:

First name

State of birth:

Is this child receiving TANF, Medicaid and/or medical benefits?  Yes

Full legal name of child:

If yes, where:

Last name

Last

Middle

City of birth: Race:

 No

First name

Social Security number: State of birth:

If Native American, what Is child enrolled w/or eligible for Has CDIB been issued? tribe? enrollment?  Yes  No  Yes  No If the child is 18, is he/she currently in Name of school: high school?  Yes  No Graduation year: State ZIP

Is this child receiving TANF, Medicaid and/or medical benefits?  Yes Will the father name anyone else as a possible father?  Yes  No

 No

If yes, who?

If yes, where:

Last name

First name

If additional children, please use the back of page. Page 4 of 8

Form no. 06579 FS-CSS Rev. 6/2017

IV. INFORMATION ABOUT CHILD SUPPORT OBLIGATION. The relationship between the mother and father of the child(ren): (check)  Never married  Married/living apart  Divorced  Lived together Date of separation:

Date of living apart:

Date of marriage:

City:

Date of decree of divorce: County:

State:

A. COURT ORDER INFORMATION. (Attach copies of your divorce decree, paternity order, custody order or any tribal orders, etc.) Date of order: Court case number: What court? City:

County:

State:

If child support was ordered, how much?

If tribal or CFR court what tribe issued the order?

Per week, bi-weekly or per month?

If a private attorney was consulted for this order, please give name, address and phone number: Name of attorney currently working on your case

Attorney’s address/phone number:

B. PENDING COURT ORDERS. (please attach copy) Is there any legal action that affects the child(ren)? Is the child(ren) in Indian Child Welfare (ICW) or DHS custody? Date child(ren) placed in ICW/DHS custody:

If child(ren) in ICW/DHS care, what tribe or county?

Date of filing:

Court case number:

County:

State:

In what court is the paperwork filed?

If tribal court, what tribe?

If child support has been ordered, how much is the non-custodial parent ordered to pay?

How often?

If a private attorney was consulted for this order, please give name, address and phone number: Name of attorney currently working on your case V.

At the time our office is able to enforce a child support order, please indicate how you would like to receive your child support payments:  Direct deposit

VI.

Attorney’s address/phone number:

or

 Check

 Debit card

COMMENTS: Please provide additional information that you feel could assist our office in enforcing your child support order. (If necessary, you may use the back of the page.)

Page 5 of 8

Form no. 06579 FS-CSS Rev. 6/2017

VII.

STATEMENT OF CHILD SUPPORT RECEIVED (directly paid to you). Use one form for payments RECEIVED from one parent. 1. If you have not received any child support payments from the non-custodial parent, please complete section A. Do not forget to sign and date the affidavit before a notary public. 2. If you have received child support from the non-custodial parent, complete section A and B. Start with the most recent year you received child support or were given a judgment and work back. Do not forget to sign and date the affidavit before a notary public. Section A: I, ____________________________________, state the following to be records of any/all direct payments from _______________________.  I have not received any child support payments form the non-custodial parent.  I have received child support payments from the non-custodial parent. These payments were made directly to me, not through the State of Oklahoma, for the following children: Child’s name

Date of birth

Section B: INCLUDE ONLY PAYMENTS RECEIVED FOR CHILD SUPPORT *Indicate by an (x) any time children were not in your care for 30 days or more. 20___ 20___ 20___ 20___ 20___ 20___ 20___ _____

_____

_____

JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER Applicant’s signature: ___________________________________

Page 6 of 8

Date: _______________________

Form no. 06579 FS-CSS Rev. 6/2017

VIII. STATEMENT OF UNDERSTANDING: 1. I understand the Chickasaw Nation Child Support Services department (CNCSS) is here to act in the public interest to protect children’s rights, protect the taxpayers, the tribe, and to make sure that the parents financially support their children. I understand that the responsibilities of the child support program do not allow the staff of CNCSS to have the same confidential relationship with me as I would have with a private attorney. Information I provide will be kept from the general public but may be used as needed to collect support from either parent. I give CNCSS permission to give any necessary information to law enforcement officers, public officials, court or others to assist me to collect child support or medical support. 2. I understand that CNCSS ensures that all personal information provided to CNCSS such as addresses, telephone numbers, employer names, etc., shall remain confidential. No personal information will be shared between the custodial parent and non-custodial parent. 3. I understand that CNCSS attorneys or child support staff do not represent me. I have the option to hire an attorney at my own expense. At the time of obtaining a private attorney, CNCSS will no longer correspond with me directly; ONLY my attorney will contact the CNCSS attorney directly. 4. I agree to fill out forms and affidavits as requested, to have genetic testing and attend court to give testimony. I agree to cooperate fully with CNCSS, law enforcement offices and the court. I will notify CNCSS of my new address in writing every time I move. 5. I agree to give all identifying information requested to assist in locating and collecting child support from the non-custodial parent (NCP) and/or prove who is the biological father of my child(ren). This includes any information that I know about or any documentation that I have. 6. I understand CNCSS cannot guarantee that it can determine who the biological father of my child is, collect the money from the NCP, enforce a court order for support or obtain a support order from the court. I understand that CNCSS cannot help with issues such as custody and property settlements. I agree to tell CNCSS if I hire a private attorney to collect or modify child support or spousal support for me. 7. I agree CNCSS will decide on the best way to collect the child support. This will include taking the overdue support from federal and state tax refunds that are due to the NCP. I understand that money collected from federal or state tax intercept will be applied to monies owed to the tribe or state first for funds expended on behalf of my children and myself. I understand that tax intercepts may take refunds due to both the NCP and current spouse on joint returns. I understand that CNCSS or state agency will hold the intercept for up to six months. I understand that I may receive tax collections that are actually owed to the NCP’s current spouse and I agree that if the NCP’s current spouse files an Injured Spouse claim for his/her portion of the tax refund collection, I will return that portion to CNCSS. 8. I agree that starting with the date of my application all money paid for child support will go through the State of Oklahoma Central Registry Unit in Oklahoma City. I give CNCSS the authority to endorse child support checks made out to me. I understand that if I do not notify CNCSS of direct payments or turn in child support paid directly to me, my case will be closed. 9. I understand if I keep child support payments to which I am not entitled because the NCP paid me directly for support assigned to the tribe or state or because payments were sent to me in error, CNCSS will recover the overpayments from me. I understand CNCSS shall be entitled to recover the overpayment by withholding amounts from my child support payments and/or through interception of my state tax refund. 10. I understand it is law that CNCSS will collect money owed to the tribe or state for any TANF/AFDC my children received in the past or is/are currently receiving. Any amount of money collected that is more than what is due every month for current support will be paid to the tribe or state for any TANF/AFDC paid to my children or me in the past. 11. I understand and agree to all the terms above. I understand that if I violate any of the agreements or fail to cooperate with CNCSS, my case will be closed. The information provided in this application is true and correct to the best of my knowledge. 12. I understand that by opening a case with CNCSS I will be closing my case with the State of Oklahoma. Applicant’s signature: ___________________________________

Date: _______________________

REMINDERS: STATE OF: _____________________

(NOTARY USE ONLY)

COUNTY OF: _____________________ I verify that the above named person signed this affidavit before me on this ______ day of _______________, 20___. Notary public: ____________________________________ My commission expires: ____________________

Commission number: ____________________________ Page 7 of 8

Form no. 06579 FS-CSS Rev. 6/2017

     

Did you read, sign and notarize the application: Statement of Understanding?  Yes  No Affidavit of Direct Payments?  Yes  No Attach copies of state issued birth certificates for all children?  Yes  No Hospital issued birth certificates with baby footprints will not be accepted. Attach copies of CDIB for all children?  Yes  No Attach copies of Social Security card(s) for all parties in case?  Yes  No Attach copies of court orders, divorce decree, affidavit(s) acknowledging paternity?  Yes Do you have any questions about the application? Please call 866/431-3419

 No

Send original application to: The Chickasaw Nation Child Support Services P.O. Box 1809 Ada, OK 74821

Would you like to visit our main office? The Chickasaw Nation Child Support Services 1301 Hoppe Boulevard Ada, Oklahoma 74820 Would you like to know more information about the Chickasaw Nation? Please visit our website at www.chickasaw.net.

DO NOT SEND APPLICATION TO OFFICE BY FAX.

Page 8 of 8

Form no. 06579 FS-CSS Rev. 6/2017