APPLICATION FOR CHILD SUPPORT SERVICES

NON-PUBLIC ASSISTANCE APPLICANT

IMPORTANT: If you are receiving ADC or Medicaid, do not complete this application, because you became eligible for child support services when you became eligible to receive ADC or Medicaid.

I, the undersigned, , request Child Support Services from the Hamilton County Child Support Enforcement Agency. I understand and agree to the following conditions:

A.	I am a resident of the County in which services are requested.

B.	Recipients of child support services shall cooperate to the best of their ability with the CSEA. (See attached rights and responsibility	information).

The Child Support Enforcement Agency can assist you in providing the following services:

1.	Location of Absent Parents.

The agency can assist in finding where an absent parent is currently living, in what city, town or state. The applicant can request “Location Services Only”, if the sole need is to find the whereabouts of the absent parent.

2.	Establishment or Modification of Child Support and Medical Support.

The CSEA can assist you to obtain an order for support if you are separated, have been deserted or need to establish paternity (fatherhood). The CSEA can also assist you in changing the amount of support orders (modification), and to establish a medical support order.

3.	Enforcement of Existing Orders.

The CSEA can help you collect current and back child support.

4.	Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages.

The agency can assist in collecting back support (Arrearages) by intercepting a non-payor’s federal and state income tax refunds on some cases.

5.	Withholding of Wages and Unearned Income for the Payment of Court Ordered Support.

The agency can help you get payroll deductions for current and back child support and can intercept unemployment compensation to collect child support.

6.	Establishment of Paternity.

The agency can obtain an order for the establishment of paternity (fatherhood), if you were not married to the father of the child. An absent parent may request paternity services.

7.	Collection and Disbursement of Payments.

The CSEA can collect the child support for you, and send you a check for the amount of the payments received. Back support collected will be paid to you until all of the back support you are owed is paid.

If you received ADC in the past and support was assigned to the state, back support collected will be paid to the state after you receive back support owed to you.

8.	Interstate Collection of Child Support.

The agency can assist you in collecting support if the payor is living in another state or in some foreign countries.

C.	The only fee you can be charged for services is a one dollar application fee. Some counties pay this fee for the applicants.

D.	In providing IV-D services, the CSEA and any of its contracted agents (e.g. prosecutors, attorneys, hearing officers, etc.) represent the best interest of the children of the State of Ohio and do not represent any IV-D recipient or the IV-D recipient’s personal interest.

APPLICANT INFORMATION (INFORMATION ABOUT YOU)
Name	Date of Birth
Social Security Number (SSN) Enter only the last four digits! XXX – XX -	Current Marital Status (Check One) Single Married Divorced Separated Deserted Widowed

Type(s) of Service(s) Requested: All services listed	Location of absent parent only

Other (please explain)

I understand that the Child Support Agency - within 20 days of receiving this application will contact me by a written notice to inform me if my case has been accepted for child support services (IV-D Services).

Signature of Applicant	Date

Applicants Name (Last, First, Middle)	Telephone Number (Home)
Address (Street/Route, P.O. Box)	(Work)
City, State, Zip Code

INFORMATION ON CHILDREN

Child 1	Child 2	Child 3	Child 4
a. Name (First name, Mi)
b. Sex
c. SSN Enter only the last four digits!	xxx-xx-	xxx-xx-	xxx-xx-	xxx-xx-
d. Date of Birth (DOB)
e. Name(s) of Absent/Other Parent
f. Has Paternity (Fatherhood) Been Established?
g. Is There An Order For Support (Yes or No)

OTHER PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT

Other Parent #1	Other Parent #2	Other Parent #3
Name
Address, City State, Zip Code
SSN Enter only the last four digits!	xxx-xx-	xxx-xx-	xxx-xx-
Date of Birth
Name of Employer
Address of Employer, City, State Zip Code
Amount of Support Ordered
Date of Support Order
Location Where Order Was Issued, City, County, State
Military Service - Give Date and Branch Entered
Arrest Record: Give Date and Place of Arrest
IF the absent/other parent has been on Public Assistance: Give Date and Place
Give Name and Address of Current Spouse of Other Parent

* Have you ever been on public assistance? Yes No

When	Where	County

Date	City and State

(Do Not Write in This Space) FOR AGENCY USE ONLY
Case Name	Date Requested	Date Mailed or Provided
Case Number	Date Returned or File Date