Free Form 03EN001E (CSED-1) - Oklahoma

OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Oklahoma Child Support Enforcement Division
Every child has the right to support from both parents.

Child Support Services and Responsibilities
Oklahoma Child Support Enforcement Division (CSED) can help: · · · · · · · locate the parent(s) of a child or the assets of the parent(s); establish paternity for a child; obtain a child support order from court for a child, including medical support; enforce unpaid child and medical insurance support; collect child support payments; review and change child support orders; and take any of these actions across state lines and in many other countries.

Who is eligible for services? · Any parent or custodial person who needs child support services for a minor child is eligible. CSED automatically provides services to current Temporary Assistance for Needy Families (TANF), Medicaid/SoonerCare (Title XIX) recipients, child care subsidy recipients, and former recipients continuing their support services and therefore a custodial person receiving these services does not need to complete a CSED application. CSED's services are for minor children and, therefore, CSED does not accept applications when all children on the case have reached the age of majority, which in Oklahoma is 18 years of age.

·

Child support services: Once a referral or application for services is received, the following services are provided by CSED free of charge. Other states may charge a fee when they provide a service to a custodial person or parent in Oklahoma. These services are available whether the parent lives inside or outside of Oklahoma. · Location of parent ­ Electronic and other types of searches are used to find the parent's address, employer, and assets, if the applicant does not know where he or she lives or works. · Paternity establishment ­ We will help establish legal paternity either by voluntary acknowledgment or through court actions. · Child support establishment ­ We will file a petition with the court to obtain a child support order. We use Oklahoma's Child Support Guidelines to establish a monthly child support amount for children. · Child care ­ We use Oklahoma's Child Support Guidelines to determine annual child care costs and allocate this amount between the parents in the same proportion as their adjusted gross income.

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Medical support establishment and enforcement ­ Children are legally entitled to health insurance coverage if it is available to the noncustodial parent. If the noncustodial parent was ordered to provide health insurance for the child and has not, we will require the noncustodial parent's employer to deduct any employee-paid health insurance premiums from his or her wages. Collection ­ Once payments are being paid through the Oklahoma Centralized Support Registry, they are tracked and promptly sent to the custodial person. Enforcement ­ We provide automatic enforcement of child support orders. Without going back to court, we can deduct child support from income, take tax refunds, and seize bank accounts. We can also ask the court to enforce the order and revoke driver, professional, and recreational licenses. Review and modification ­ CSED can review support orders to make sure they are for the correct amount allowed by law. If appropriate, we ask the court to modify the current support amount.

Help us help you! Be as complete as possible when you furnish information to CSED. The more information you provide, the faster we can help you. You may use the back of the form if you need more space to write. Keep us informed about the other parent's: · · · current address and phone number; current work address and phone number; and Social Security number.

Other information: Send CSED copies of: · any order establishing paternity or granting a divorce; · all child support orders already entered by a court; and · all child support orders changing child support requirements or custody of child(ren). You must understand: · · · · CSED will select and use appropriate child support establishment and enforcement actions depending on circumstances. CSED attorneys and other staff do not represent you or the other party to your child support case. Information you provide CSED may be released to others if needed to establish an order and collect child support or medical support for the children. The address you provide may be used by CSED and others for service of papers. You must provide your Social Security number. CSED will use it for child support enforcement purposes as defined in Title IV, Part D of the Social Security Act. Social Security number information may be released to the noncustodial parent(s) and others for a number of reasons including, but not limited to, collecting child support payments and enrolling the children in health insurance programs.

Application for Child Support Services · · ·

03EN001E (CSED-1)

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If you receive any money that you are not entitled to, you must pay it back. CSED may hold back all or a portion of your support payments to recover what you owe. If federal tax refunds are intercepted for support owed, that money will be held for six months if it is a joint return for the noncustodial parent and his or her current spouse. CSED has authority to endorse and negotiate payments related to child support, including cashier and personal checks, money orders, and credit card, debit card and direct debit payments from your bank account, on your behalf and on behalf of children in your case. CSED operates a Centralized Support Registry for the receipt and disbursement of support payments. In order to receive your support payments, you will initially be issued the Oklahoma MasterCard Debit Card (debit card). For debit card questions, contact the toll-free customer service number, 1-888-401-9843, located on the back of your debit card. You may enroll in direct deposit at any time by calling the toll-free customer service number located on the back of your debit card. There are no charges or fees for receiving your funds by direct deposit, however, you will need to open a bank account to do so. Normal banking charges may apply, so check with your bank. Some automated teller machine (ATM) withdrawals will be provided free with your debit card, but some ATMs charge transaction fees. Tips on how to use your debit card will be provided with your card. If you're the noncustodial parent requesting CSED services, your payment methods could include cashier and personal checks, money orders and credit card, debit card and direct debit payments from your bank account. CSED does not accept temporary checks for child support payments. CSED reserves the right to refuse to accept a personal check or direct debit after receiving a non-sufficient funds personal check or direct debit from the same bank account. CSED distributes child support as required by federal and state law. Current support is applied to the month in which it is received by CSED. Some parents pay support for children in more than one household. If a payment does not cover all the current support obligations, it may be divided so that each household receives a share. After all child support payments are made, the remaining money is applied to past-due amounts. If the custodial person received TANF [formerly Aid to Families with Dependent Children (AFDC)], collections from intercepting the noncustodial parent's federal tax refund are used to repay the amount of assistance the custodial person received. The post office does not forward child support payments to a new address you have provided them. You must inform CSED of your new address in order to receive your child support payments, and court and other legal documents.

You agree to: · · · · · cooperate with CSED workers by providing requested information; inform CSED every time the address changes for you or your children; forward to CSED all support payments you receive from anyone other than CSED; tell CSED if you ask another person or agency to collect child support for you; and report to CSED immediately, in writing, any new or changed information that relates to collecting child support from the noncustodial parent. CSED contact information: Oklahoma City area: 405-522-CARE (2273) Tulsa area: 918-295-3500 Toll free: 1-800-522-2922 TTY in Oklahoma City area: 405-522-3792 TTY toll free: 1-866-264-4767 http://www.okdhs.org/programsandservices/cse/

Your support payments must be mailed to: Oklahoma Centralized Support Registry P. O. Box 268849 Oklahoma City, Oklahoma 73126-8849

*03EN001E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES Child Support Enforcement Division

Application for Child Support Services
OFFICE USE ONLY Date requested: Request type: Phone Walk-in Date sent: Internet

Mail

IVR

I.

Services requested. I request:

Full CSED services. Locate only services.

II. Person applying for child support services.
· I am the custodial person. I request services for the child(ren) who lives with me. Check one or both boxes. I seek child support from: the child(ren)'s mother. the child(ren)'s father. · I am the noncustodial parent. I request services for the child(ren) who lives with the custodial person listed in Section III.

I request child support services because:

III. Custodial person. All questions in this section pertain to the person with whom
the child(ren) lives. Please print all information. Full legal name, last Maiden name/other names used Date of birth Area code Home phone First Middle Social Security number Area code Daytime phone

Sex Race If Native American, what tribe? Male Female What is the relationship of the custodial person to the child(ren)? Name of person with legal custody Mailing address Home street address City City County State State Zip code Zip code

E-mail address for daytime contact

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03EN001E (CSED-1)

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03EN001E (CSED-1)

Application for Child Support Services

If you are the custodial parent, where do you want your payments mailed? Home address Mailing address Employer's name Area code Employer's phone Employer's street address City State Zip code Yes No No

Is child(ren) receiving benefits, such as TANF or SoonerCare (Medicaid)? In what state are the benefits received?

Is a private or government agency currently working on child support case? Yes Agency retained by: Custodial person Other Name of agency Street address City Area code State Phone Zip code Yes

Is a private attorney currently working on the child support case? Private attorney retained by: Custodial person Other Name of private attorney Street address City Phone State

No

Zip code

IV. Family violence. Do you believe you or your child(ren) could be at serious risk
of emotional or physical harm if the other parent knows where to find you? If so, you may request your location information be protected by Child Support Enforcement Division (CSED). To do so, you must complete Form 03EN008E, Family Violence - Address of Record Statement, and submit it with this application. To request Form 03EN008E, contact CSED at 405-522-2273 or TTY at 405-5223792 in the Oklahoma City calling area, 918-295-3500 in the Tulsa calling area, or toll free at 1-800-522-2922 or TTY at 1-866-264-4767. CSED uses Form 03EN008E to update your official address of record. Otherwise, under Oklahoma law, your physical location information may be released to the other parent or person on your case. Address of record. An address of record is a public address where you will accept payments and legal and other official papers by regular mail, such as your private attorney's address, if you have one. This address will be printed in legal/court documents and, therefore, may be provided to the other parent or person on your case. If family violence is an issue, this address of record must be different from a home address.

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Application for Child Support Services

03EN001E (CSED-1)

V. Information about the parent(s). Please print all information.
Father or person who may be the father, if not the custodial person. Full legal name, last Father's present State Zip code First Middle City Other names used County last known phone number

or last known street address Area code Father's

present or

Is father currently married? Yes No Employer's name Current Employer's street address

If yes, father's spouse's full name? Last known City Area code State Employer's phone Zip code

Usually employed as a (plumber, mechanic, fast food) Does father have an occupational license, such as doctor or electrician? Yes If yes, what kind? Does the father have a lifetime hunting or fishing license? Does the father belong to a union? If yes, what is the name and address of the union? Union name Address Yes No Yes Yes No No No

Are there any pending lawsuits or claims for money? Is yes, please explain.

Father's description. Photograph attached? Yes Birthplace, City Social Security number Hair color State Race Date of birth

No

Date of photograph:

If Native American, what tribe?

Height

Weight

Eye color

Identifying marks, such as scars or tattoos Yes No State

Has father been in jail or prison? When? Location, City

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03EN001E (CSED-1) Has father been on probation or parole? Yes

Application for Child Support Services No

Name of parole or probation officer and city and state Is father retired? Where did he work when he retired? Is father disabled? Is father employed by Yes No Yes No

the state of the federal government, agency of the tribal government of the military, branch of Make License plate number Model State

Information about the father's vehicle. Year of vehicle Color

Does father own any property or assets? If yes, list below. Real estate

Yes City

No County State

Registered vehicles, other than the one listed above Name and address of financial institution and account numbers Other possessions of value, such as stocks, bonds, jewelry, pensions, or gun collections

Information about the father's parents. Mother's last name Street address Father's last name Street address First City First City Middle Middle Area code State Area code State Phone Zip code Phone Zip code

What else can you tell us that may help us locate the father?

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Application for Child Support Services Mother, if not the custodial person. Legal last name Mother's State present or First Middle

03EN001E (CSED-1)

Maiden/other names used City County

last known street address Mother's present

Zip code

Area code

or last known phone number

Is mother currently married? Yes No Employer's name Current Employer's street address

If yes, mother's spouse's full name Last known City Area code State Employer's phone

Zip code

Usually employed as a waitress, office worker, or fast food Does mother have an occupational license, such as beautician or doctor? If yes, what kind? Does mother have a lifetime hunting or fishing license? Does mother belong to a union? If yes, what is the name and address of the union? Union name Address Yes No Yes Yes Yes No No No

Are there any pending lawsuits or claims for money? If yes, please explain.

Mother's description. Photograph attached? Yes Birthplace, City Social Security number Hair color State Race Eye color Date of birth

No

Date of photograph:

.

If Native American, what tribe? Height

Weight

Identifying marks, such as scars or tattoos

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03EN001E (CSED-1) Has mother been in jail or prison? When? Location, City

Application for Child Support Services Yes No State Yes No

Has mother been on probation or parole?

Name of parole or probation officer and city and state Is mother retired? Where did she work when she retired? Is mother disabled? Is mother employed by Yes No Yes No

the state of the federal government, agency of the tribal government of the military, branch of Make License plate number Yes City Model State No County State

Information about the mother's vehicle. Year of vehicle Color

Does mother own any property or assets? If yes, list below. Real estate

Registered vehicles, other than the one listed above Name and address of financial institution and account numbers Other, possessions of value, such as stocks, bonds, jewelry, pensions, or gun collections Information about the mother's parents. Mother's last name Street address Father's last name Street address First City First City Middle Middle Area code State Area code State Phone Zip code Phone Zip code

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Application for Child Support Services What else can you tell us that may help us locate the mother?

03EN001E (CSED-1)

VI. Information about the child(ren). Information in this section concerns the
child(ren). Please print all information. List only those children belonging to the same mother and father. A child(ren) of a different set of parents requires a separate application. Legal last name of child Social Security number First Date of birth Middle

If Native American, what tribe? Was the child born in Oklahoma? Yes No

Sex Race Male Female Estimated high school graduation date If no, where was the child born?

Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. Legal last name of child Social Security number First Date of birth Middle

If Native American, what tribe? Was the child born in Oklahoma? Yes No

Sex Race Male Female Estimated high school graduation date If no, where was the child born?

Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. Legal last name of child Social Security number First Date of birth Middle

If Native American, what tribe? Was the child born in Oklahoma? Yes No

Sex Race Male Female Estimated high school graduation date If no, where was the child born?

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03EN001E (CSED-1)

Application for Child Support Services

Legal status: Support ordered for this child. Paternity established, no support ordered. Paternity needs to be established legally. Parents married, living apart, no support ordered. What amount is paid for child care to allow the custodial person to be employed or attend school? Amount $ Check one: Weekly Biweekly Monthly

VII. Information about the child support obligation and custody of the children. Please print all information.
What is the current relationship between the mother and father of the child(ren)? Never married Date of marriage ceremony Married/living apart County Divorced State

Provide a copy of any court order, such as divorce, paternity order, custody order, or tribal order. Attach a copy to this form. If you do not have a copy, fill in the blanks below. Date of court order Court case number County Where? Yes State Court

If tribal court, what tribe?

Are there any legal actions pending that affect the child(ren)? Check all that apply: Visitation Custody Other If yes, provide a copy and fill in the blanks below. Date of filing Case number County State

Court

If child support has been ordered, how much is the noncustodial parent ordered to pay? $ How often? Have there been any changes to the child support order? If yes, provide a copy Date of changes: What were the changes? Use the space on page 8 to record additional information. Yes No

Health insurance coverage. Who is the provider of the health insurance? Father Mother Other person

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Application for Child Support Services Is the child(ren) enrolled in a health insurance plan? If yes, which child(ren) is enrolled? Yes No

03EN001E (CSED-1)

What is the cost per month to cover only the child(ren)? $ Name of insurance company Street address of insurance company Health insurance group number City

Effective date

State

Zip code

Area code Phone

Policy number

Does the child(ren) receive medical services from an Indian health agency? Yes No Child support payments. Please send me an access code so that I can obtain child support payment information over the telephone or the Internet. After submitting your application you must forward to CSED all support payments you receive from anyone other than CSED. Mail payments to: Oklahoma Centralized Support Registry P.O. Box 268849 Oklahoma City, OK, 73126-8849 The CSED Web site is http://www.okdhs.org/programsandservices/cse/. Additional comments:

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03EN001E (CSED-1)

Application for Child Support Services

VIII. Statement of child support payments received. If more than one parent
has paid child support, copy this page and complete one for each parent. Office use only Court case no.: Custodial person name Child's name Child's name Child's name 1. 2. I, in the amount of $ OK IV-D case no.: Noncustodial parent name Child's date of birth Child's date of birth Child's date of birth , state that child support .

per month is due from

I, , have received no child support from the noncustodial parent. Do not fill out the remainder of the form. Please sign and date the form. OR

3. I, , have received child support payments from the noncustodial parent as shown below. List all child support payments below. Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $

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Application for Child Support Services

03EN001E (CSED-1)

Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $

Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $

Month Year: Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $

4. The following is an explanation regarding the period(s), if any, for which support may be due but no request is being made to collect:

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct. Signature of custodial person Date and place

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03EN001E (CSED-1)

Application for Child Support Services

IX. Paternity questionnaire. Skip this section if paternity is not in question.
Complete one paternity questionnaire for each child. Please print all information. Information about the mother of the child. Legal last name Currently pregnant? Yes No Legal last name First Middle Date of birth When is the baby due?

If yes, who is the biological father?

Information about the child. First Middle Date of birth If no, what state? No

Was the child conceived in the state of Oklahoma? Yes No

Has a voluntary acknowledgment of paternity form been signed on child? Yes If yes, date completed: Provide a copy. If yes, what state? Has the acknowledgment been withdrawn? If yes, date withdrawn: Yes

No No No

Has genetic testing to determine paternity been conducted for this child? Yes If yes, please explain. If father lives outside Oklahoma, has he ever lived or worked in Oklahoma? Yes Has he lived in Oklahoma? Yes No When and where?

Has he worked in Oklahoma?

Yes

No

When and where?

Information about the mother's relationship with the alleged biological father. Has the alleged biological father ever paid any bills for this child? If yes, attach a list of dates and amounts. Keep the receipts, if any. Did the mother have a sexual relationship with anyone other than the alleged biological father within 90 days before or after the date the mother became pregnant with this child? Last name of this person Mailing address First City Middle State Yes No

Yes

No

Phone Zip code

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Application for Child Support Services Has any other person been named as the father of this child? Yes No If yes, person's full name

03EN001E (CSED-1)

Information about the mother's husband when the child was born. Please complete this section if the mother had a husband at the time of this child's conception or birth and the husband is NOT the father of the child. Legal last name Address: present Street address Husband's description. Date of birth Social Security number Birthplace Race Height Weight Hair color First or last known City State Zip code Phone number Middle Other names used

Identifying marks, such as scars or tattoos Current employer's name Area code Employer's phone

What is the current relationship between the husband and the mother of the child? Married Divorced date of divorce: Married/Separated Type of marriage Common-law Licensed Yes No Has a court order stated the ex-husband is not the father? Attach a copy of all orders.

X. Comments. Please write any comments you may have.

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03EN001E (CSED-1)

Application for Child Support Services

XI. Signature required.
By signing this application, I authorize CSED to: · take child support establishment and enforcement action CSED finds appropriate; and · endorse and negotiate payments related to child support and spousal support, including checks, money orders, bank drafts, and electronic payments on my behalf and on behalf of the child(ren) in my case, if I am the custodial person. I understand: · CSED and others may use the address I provide for service of papers; · the post office does not forward child support payments to a new address I have provided them. I must inform CSED of my new address in order to receive my child support payments, and court and other legal documents; · CSED attorneys and staff do not represent me; · if I receive support to which I am not entitled, I must pay it back. CSED may hold back all or a portion of my support payments to recover what I owe; and · the penalty for perjury on a document that will be used in a judicial proceeding is five years in prison and a $1,000 fine. I read and understand the Child Support Services and Responsibilities at the beginning of this application. Further, I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that all of the information I have given, particularly information that relates to all individuals who might be the father of the child(ren), is true and correct. I acknowledge the truth of all information provided in all sections in this information packet. I understand this acknowledgment applies to the information packet as a whole and to each individual section.

Signature of applicant Did you: · · · · sign this application (Form 03EN001E)? make a copy of this form for your records? enclose a copy of all court orders? send this application and court orders to:

Date and place

Oklahoma Centralized Support Registry P.O. Box 268876 Oklahoma City, OK 73126-8876

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