Free Bureau for Child Support Enforcement - Application and Income Withholding Form - West Virginia

BUREAU FOR CHILD SUPPORT ENFORCEMENT
APPLICATION AND INCOME WITHHOLDING FORM This Form MUST Be Completed In All Cases Involving Minor Children or Spousal Support! County: _________________________ Civil Action No. ____________

Withholding services will begin immediately when the Bureau for Child Support Enforcement receives this completed application, which MUST be accompanied by a copy of the current Support Order IF one is now in effect. ___ Check this blank if a Support Order is NOW in effect. Petitioner Full Name: _________________________ Birth date: _______ SSN: ___________ Sex: _____ Relationship to children involved in this case: _______________________________ Residence Address: _____________________________________________________________ (List com plete physical address: county; city; street #; apt. #; zip code.) Mailing Address: _____________________________________________________________ (List mailing address O NLY if different from physical address.) Daytime phone #: ____________________ Driver's License #: ______________________

Respondent Full Name: _________________________ Birth date: _______ SSN: ___________ Sex: _____ Relationship to children involved in this case: _______________________________ Residence Address: _____________________________________________________________ (List com plete physical address: county; city; street #; apt. #; zip code.) Mailing Address: _____________________________________________________________ (List mailing address O NLY if different from physical address.) Daytime phone #: ____________________ Dependents Driver's License #: ______________________

( List full nam e; sex; birth date; social security #; and custodian for each de pendent.)

__________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________________________ Income Withholding
(List com plete address of the employer or other source of income to which an Income

W ithholding Notice should be sent. ) ______________________________________________________________________________

___ Check this blank if YOU WOULD FEAR FOR YOUR SAFETY, or THE SAFETY OF YOUR CHILDREN if your address and telephone number are disclosed. ___ Check this blank if you currently receive TNAF benefits.

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SCA -FC-11 3 (12/01)

Bureau for Child Support Enforcement Application

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___ Check this blank if you or one of your children currently receives a DHHS Medical Card. ___ Check this blank if you currently receive, or have applied for DHHS Child Support Services. IF YOU CHECKED any of the four items immediately above, skip to the end of the form, SIGN on the line provided, and you are done. IF YOU DID NOT CHECK any of the four items immediately above, YOU MUST CONTINUE! ___ I understand that unless otherwise directed by the court, any court ordered support MUST be collected by the BCSE through Income Withholding.

YOU MUST CHOOSE ONE OF THE THREE FOLLOWING OPTIONS! OPTION # 1. ___ I am applying for FULL SERVICES from the BCSE. I understand that full services include, but are not limited to the following: *Collection and distribution of support payments. *Collection and enforcement of support by income withholding. *Establishment and enforcement of Support Orders. *Establishment of paternity. *Enforcement of Support Orders through Federal and State Tax offsets, unemployment compensation intercepts, and workers' compensation intercepts. *Location of parent(s). *Interstate services. ___ As an applicant for FULL SERVICES, I AGREE to comply with the following requirements: 1. I understand I MUST assist the BCSE to establish and enforce paternity, child support, and medical support, and to collect child and spousal support. I understand this assistance may include providing information about the non-custodial parent, and responding promptly and completely to requests from the BCSE. I understand I may be required to testify as a witness in court, or in other proceedings. 2. I understand that I am free to pursue legal actions through a private lawyer, but that I must inform the BCSE if I do this. 3. I understand that I MUST repay all money received in error to which I am not entitled. OPTION # 2. ___ I am applying for Income Withholding Services ONLY. OPTION # 3. ___ I DID NOT CHECK Option #1 or Option #2. I do not want services from the BCSE at this time. ___ I understand that even though I have not requested services at this time, I can request services at any time by applying at the BCSE office in the county in which I live. I CERTIFY that I have read and understand all statements on this application, and that all information I have provided is TRUE and ACCURATE to the best of my knowledge. Signature: _______________________________________________ Date: ________________

SCA -FC-11 3 (12/01)

Bureau for Child Support Enforcement Application

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