Free Form 03EN002E (CSED-1-A) - Oklahoma

*03EN002E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Affidavit of Child Support Payments Received
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 $ $ $ $ $ $ $ $ $ $ $ $

OKDHS issued 7-1-2007

03EN002E (CSED-1-A)

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03EN002E (CSED-1-A)

Affidavit of Child Support Payments Received

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

Year: $ $ $ $ $ $ $ $ $ $ $ $

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

Year: $ $ $ $ $ $ $ $ $ $ $ $

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

Year: $ $ $ $ $ $ $ $ $ $ $ $

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

Mail this form to your Oklahoma Department of Human Services (OKDHS) county office. The OKDHS county office forwards Form 03EN002E to the appropriate OKDHS Child Support Enforcement Division (CSED) district office.

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OKDHS issued 7-1-2007

Affidavit of Child Support Payments Received

03EN002E (CSED-1-A)

Purpose of form Form 03EN002E is completed, signed, and dated by the custodial person in order to proceed with the process of establishing and enforcing child support orders. Depending upon the circumstances, Form 03EN002E may not be the only form required to establish and enforce child support orders. Instructions 1. Use a black ink pen to complete Form 03EN002E. 2. Complete statement number 1 child support has been ordered against a noncustodial parent. 3. If you have not received child support from the noncustodial parent, complete statement number 2 and do not fill out the remainder of the form. Please sign and date the form. Return the original Form 03EN002E to the Oklahoma Department of Human Services (OKDHS), Family Support Services (FSS) intake worker. The FSS intake worker forwards Form 03EN002E to the appropriate OKDHS Child Support Enforcement Division (CSED) district office. 4. If you have received child support from the noncustodial parent, complete statement number 3 and start with the most recent year you received child support or were given a judgment for lack of support, and work back. Please sign and date the form. Return the original Form 03EN002E to the FSS intake worker. The FSS intake worker forwards Form 03EN002E to the appropriate OKDHS CSED district office. Write in only payment amounts for child support and spousal support (alimony). 5. If Form 03EN002E is not completed at the time of application for services, it must be completed and returned within ten days of the notice of certification for services.

OKDHS issued 7-1-2007

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