Free 34882.FH11 - Indiana

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES
State Form 34882 (R8 / 3-07) / CSB 425A Approved by State Board of Accounts, 2006

Take or mail this completed form to your county prosecutors office.
PRIVACY STATEMENT
*The records in this series are confidential according to Indiana Department of Child Services 42 USC 653, 42 USC 654, and 42 USC 663. This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purposes of the agency as are also required by these statutes. Disclosure of this information is mandatory. Failure to provide any information may prevent this form from being processed.

INSTRUCTIONS:

1. Complete one application for each non-custodial parent for whom application is made. INSTRUCTIONS (please read)

The Indiana Child Support Bureau offers child support services to persons desiring to obtain child support from a responsible parent outside the home. These services are: Complete Service or Parent Locator Only Service. ALL FEES FOR SERVICES ARE NON-REFUNDABLE. COMPLETE SERVICE: The applicant will be entitled to all services offered by the IV-D program as long as the case remains active. This service shall include the Parent Locator Service and the legal services of the local IV-D agency. These services include Establishing Paternity, Establishing and/or Enforcing a support obligation (including health insurance coverage). The complete service does NOT include handling a divorce case, enforcement of custody or visitation provisions, nor matters other than those associated with the support of dependent children. All support payments may be directed to the State for monitoring and disbursement. ANY COSTS INCURRED IN EXCESS OF THE APPLICATION FEE, SUCH AS COURT COSTS, WITNESS FEES, BLOOD TEST COSTS, IRS INTERCEPT FEES AND ADMINISTRATIVE COSTS ASSOCIATED WITH THIS CASE MAY BE CHARGED AGAINST THE APPLICANT. In addition the Tax Refund Intercept Project may be used to collect child support arrearages. Application for complete service does not guarantee, however, that your case will be submitted for tax refund intercept nor that tax refund monies will be collected. In order to certify a case for intercept, there must be a valid child support order, the absent parent must be at least $500 in arrears, and the applicant must have the non-custodial parent's Social Security number. If any children of the non-custodial parent have received TANF/AFDC in the past, any collection made from an intercept will first be applied by the State to any unreimbursed public assistance on any former TANF/AFDC case. If the IRS, for any reason, reclaims all or any portion of an intercepted refund that has already been paid to you, you are obligated to repay the State of Indiana the amount reclaimed by the IRS. You authorize that any such repayment may be deducted from support collected on your behalf if other arrangements have not been made and fulfilled. PARENT LOCATOR SERVICE: The applicant will be entitled to all resources offered by the State and Federal Parent Locator Service until a verified address is provided or all sources for location are exhausted. The payment of the application fee does not guarantee a successful location. The success will greatly depend on the applicant's own knowledge about the absent parent. If all sources of information are exhausted without a successful location, the applicant will be notified. Upon notification, the applicant will have six months to provide additional information. If no additional information is provided within the six month period, the case will be closed and the applicant notified. TERMINATION OF SERVICES: The applicant may terminate services, only if any charges due or overpayments owing are paid, by notifying the Child Support Bureau in writing that services are no longer desired. The State may terminate services only in accordance with 45 C.F.R. 303.11. Services in respect to this application will also terminate if the applicant receives TANF/AFDC. APPLICANT'S OBLIGATIONS: The applicant is expected to fully cooperate with the local IV-D agency in the legal and non-legal preparation of the case, including, but not limited to notifying the local IV-D agency of change of address, supplemental information regarding the noncustodial parent, reuniting with the non-custodial parent, and other information pertinent to the case. THE APPLICANT MUST ALSO NOTIFY THE CHILD SUPPORT BUREAU AT THE ABOVE ADDRESS OF ANY CHANGE OF ADDRESS.
APPLICANT'S STATEMENT

I affirm that the information in this application is true and correct and that false information could result in perjury charges against me. I understand that I am to cooperate with the local IV-D agency in order for my case to be processed, and non-cooperation can result in termination of my case. I further understand that payment of the application fee does not guarantee successful action on the case but rather all reasonable attempts will be made in my behalf to obtain successful results for the service requested. I have read and understand the above NOTICE.
I hereby request the following service under the terms outlined above.

Complete Service
Signature of applicant Application taken by:

Parent Locator Service Only
Date signed (month, day, year) Fee paid Case number

$ Page 1 of 4

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)
State Form 34882 (R8 / 3-07) / CSB 425A

To be completed by County Office: Case number

PART II: APPLICANT DATA
1. Full name of applicant (last, first and middle initial) 2. Date of birth (month, day, year) Sex Race Social Security number * Maiden

3. Address of applicant (numberand street or rural route number, apt. or room number, city, state, and ZIP code)

4. My mailing address is:

Same as above

Different (if different, print below)

Mailing address of applicant (number and street or rural route number, apt. or room number, city, state, and ZIP code)

5. Telephone number (home)

Telephone number (work)

(
Name

)

(

)
Telephone number

6. Address of other person who will always know my whereabouts:

(
Address (number and street, city, state, and ZIP code) 7. Have you ever received an AFDC Welfare check in Indiana? If "Yes" give the month and year of the last check Relationship

)

The county your case was in?

Yes

No PART III: DEPENDENT DATA I wish to secure support payments on behalf of the following children.

CHILD'S FULL NAME (last, first, M.I.)

BIRTHDATE SEX (month, day, year)

PLACE OF BIRTH

SOCIAL SECURITY NUMBER *

RELATIONSHIP TO ME

1. 2. 3. 4. 5. 6.
For this non-custodial parent I desire:

Parent Locator Service
Name of applicant A. Full name of non-custodial parent (last, first and middle) Social Security number * Race B. Non-custodial parent's address Date of birth (month, day, year) Height

Complete Service

PART IV: NON-CUSTODIAL PARENT DATA

Alias or maiden name (last, first, middle) Age Weight Place of birth (city and state) Hair Eyes

Number and street or rural route number, apartment or room number

Current

Last known ______ (years)

City, state, and ZIP code

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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)
State Form 34882 (R8 / 3-07) / CSB 425A

To be completed by County Office Case number

C. Employer's address

Name of employer

Number and street or rural route number Usual type of work

Current

Last known ______ (years)

City, state, and ZIP code D. Marital status of children's parents Date married (month, day, year)

Location married

Married Divorced Separated
E. Complete if parent:

Deserted Never married Unknown

Date separated or divorced (month, day, year) Branch of service

Is currently
Rank

Or has been in the military service Enlisted
Where

Marines
Service number

Army Air Force

F. Names of the non-custodial parent's children. (check Navy box in front of name if there is "No" support order for this Coast Guard child.) 1.

Officer
G. Prior arrest record

Date (month, day, year)

2. 3. 4.

Yes
Name of institution

No Is currently has been in the past in a jail, prison or institution
Date sentenced (month, day, year) Date released (month, day, year)

The non-custodial parent

Address (number and street, city, state or county) H. Non-custodial parent's father's and mothers (include maiden) name Address (number and street, city, state or county) I. Other contact person for absent parent Address (number and street, city, state or county)

5.
Verification and comments:

J. COMPLETE THIS SECTION IF CHILD IS BORN OUT OF WEDLOCK (place all other paternity information in comment section)
Has paternity suit been filed? Date (month, day, year) Place Has parent ever paid support or medical or bought things for these children?

Yes Yes

No
Date (month, day, year) Frequency

Has paternity been established by court order? Amount

No

Yes

No

$
K. COURT DATA (all applicants must complete this section)
Has parent ever been ordered by a court to pay support for these children? Name of court Address of court (number and street, city, state, and ZIP code)

Yes Yes

No No
Frequency Non-custodial parent paying support?

If No, has a petition been filed and a hearing pending? Cause number of court order To whom does parent pay support? Amount

$
Date last paid Is parent paying military allotment? Amount

Yes Yes No TO BE COMPLETED BY COUNTY OFFICE

No

Pays to me
Application taken by:

To Clerk's office

$
Date (month, day, year)

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES - ASSIGNMENT FOR COLLECTION FOR PERSONS NOT RECEIVING PUBLIC ASSISTANCE
Name of non-custodial parent

NAMES OF CHILDREN 1. 2. 3. 4. 5. 6. 7. 8. Page 3 of 4

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)
State Form 34882 (R8 / 3-07) / CSB 425A

To be completed by County Office Case number

AGREEMENT

I understand and agree that support payments collected hereafter from the non-custodial parent named above on behalf of myself and/or the above named children will be paid to the Division of Family and Children, Family and Social Services Administration, and that said support payments will be paid to me by the agency after deduction of any charges due and owing to that agency. Such charges are explained in page one of the "Application for Title IV-D Child Support Services" executed by the applicant. This authorization shall continue in effect until terminated in the manner set forth on page one of the "Application for Child Support Services".
Printed name of applicant

Signature of applicant

Date signed (month, day, year)

X
Cause number of support order Name of court

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