Free 51797 (8-04).FH11 - Indiana

REQUEST FOR CASE CLOSURE
State Form 51797 (8-04) / CSB 0009

DATE: NAME:
Tile IV-D case number

RE:

NCP name

PLEASE RETAIN THIS PAGE FOR YOUR RECORDS AS YOUR NOTICE OF THESE FACTS. The Title IV-D Child Support Program has received a request from you to close the above referenced IV-D case. Please review carefully the information below. If you meet the criteria to close your case, understand the ramifications of case closure and still wish to close your case, please sign and date the attached form and return it to the address provided. YOUR CASE CANNOT BE CLOSED IF ANY OF THE FOLLOWING CIRCUMSTANCES EXIST: You are currently receiving assistance as a TANF recipient. You formerly received TANF assistance for a child for whom paternity has not been established, and for whom the establishment of paternity and an order for child support can still be obtained. You are currently receiving Medicaid Assistance which began after July, 2000 for a child for whom paternity has not been established, and / or for whom there is not an order requiring the provision of health insurance from the noncustodial parent. IF NONE OF THE ABOVE CRITERIA APPLY AND YOU WISH TO HAVE YOUR CASE CLOSED: You will not be entitled to receive any support enforcement services from the prosecutors child support office. These include paternity establishment, parent locator, establishment and enforcement of support orders, income withholding orders, and tax refund offsets. If your case was previously a public assistance case (AFDC / TANF), the state will process support payments and tax offsets in accordance with the applicable federal and state IV-D law governing the distribution of collections. To assure timely delivery of support payments to which you are entitled, you must notify the Clerk of the Circuit Court where support payments are collected for this case of any change of your address. If you become a TANF recipient in the future, you will again be referred to the IV-D program, and your participation and cooperation will be required. If you wish to receive IV-D child support services in the future as a non-TANF case, you will be required to pay the required application fee. If your case is eligible for closure and, after reading the above information, you wish to have it closed, please return the attached Request for Case Closure form to your local Prosecutors office.

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REQUEST FOR CASE CLOSURE
State Form 51797 (8-04) / CSB 0009

The information contained on this form is CONFIDENTIAL according to 45 CFR 303.21 and 45 CFR 303.70.

YOUR CASE WILL REMAIN OPEN UNTIL THIS SIGNED FORM IS RETURNED TO: YOUR LOCAL PROSECUTORS OFFICE CHILD SUPPORT DIVISION. I hereby affirm that I have read and understand the conditions of case closure provided to me in writing. I believe my case to be in a status that allows it to be closed at my request, and I understand the ramifications of my decision. I am therefore requesting that my Title IV-D child support case be closed upon receipt of this notice.
Printed name of requestor Address (number and street, city, state, ZIP code)

Social Security number * Name of non-custodial parent Signature of requestor

Date of birth (month, day, year) * According to 45 CFR 303.21, the request for your Social Security number is MANDATORY and this form cannot be processed without it.

Date signed (month, day, year)

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