Legal Forms, Documents and Contracts

Over 4550 free forms and legal documents. Find and download the one you need!

Application for Child Support Services

Application for Child Support.pdf Form allows you to apply for the Child Support Services Division.Download

Extracted Text for Proper Search

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 1 of 12 
 	
 
 	
STATE OF ALASKA 	
DEPARTMENT OF REVENUE 
CHILD SUPPORT SERVICES DIVISION 	
 	
 	
CUSTODIAN’S APPLICATION FOR SERVICES 	
 
 
Custodial parents and other custodians must complete an application for services to obtain Child Support 
Services Division (CSSD) services.  CSSD can then establish paternity, establish child support and medical 
support orders, and enforce or modify existing support orders, even if the non custodial parent lives in another 
state.  CSSD charges no fees, although the cost of determining paternity may be charged to the father.  CSSD 
collects and distributes payments from non custodial parents; we do not provide the child support funds.  When 
child support is established by CSSD in an administrative order, the amount is calculated based on the Alaska 
Supreme Court child support rule, Civil Rule 90.3.   
 
The application and the “Statement of Support Received” must be completed and signed separately.  Additional 
information about the application, your responsibilities, CSSD services, and public assistance is found on the 
next three pages of this application packet.  If an existing order from a court, from CSSD, or from another child 
support agency mentions child support, custody, visitation, or parental rights, include it with your application. 
 
If you or your children have been victims of domestic violence, you may ask that your location be kept 
confidential by completing the “Affidavit and Request for Address Confidentiality” on page 11. 
   
After you have submitted your application, your case will be set up within 20 days.  It may take 60 days or more 
to make progress toward establishing or enforcing an order.  During that time, contact us if you have additional 
information or important questions.  Our automated KIDSLINE provides answers to common questions and 
allows you to access payment information and leave messages for caseworkers.  Also, you may visit one of our 
offices or go to our web page at www.childsupport.alaska.gov	
 for more information.  Please let us know if you 
need assistance or other accommodations to use our services. 
 
 
 
KIDSLINE: (907) 269-6900             KIDSLINE Toll Free (in Alaska): 1-800-478-3300 
TDD machine:  (907) 269-6894        TDD machine Toll Free (in Alaska):  1-800-370-6894 
 
 
Statewide – Main Office   Fairbanks     Mat-Su 
550 W 7	
th Ave Suite 310      675 7	th Ave  Station J2   845 W Commercial Dr 
Anchorage AK  99501-6699      Fairbanks AK 99701-4531     Wasilla AK 99654-6937 
(907) 269-6900     (907) 451-2830   (907) 357-3550 
 
  Southeast      Mailing address for payments  
  240 Main Street, First Floor    CSSD   
  PO Box 110402     PO Box 100380 
  Juneau AK 9981-0402    Anchorage AK 99510-0380 
  (907) 465-5887

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 2 of 12 
 
 
 	
STATE OF ALASKA 
DEPARTMENT OF REVENUE 
CHILD SUPPORT SERVICES DIVISION	
 	
 	
INFORMATION ABOUT CHILD SUPPORT SERVICES 	
 
 
Child Support Services 
You are required to provide your social security number to CSSD.  This is mandatory under federal law at 42 
USC Section 405 (c)(2)(C).  Your social security number will be used by CSSD to identify and locate you for 
the purposes of establishing paternity and establishing, modifying and enforcing support obligations.  You will 
be asked for your social security number when you call CSSD so we can identify your case.  We may also ask 
for your social security number on forms you may need to complete in order for CSSD to help you. 
 
CSSD provides child support services for parents or third-party custodians.  CSSD can:	
 	
 collect and distribute child support payments; 
 establish paternity; 
 establish child support and medical support orders; 
 enforce child support orders, even if the paying parent is not in Alaska; 
 modify support orders if there is good reason; 
 require banks, employers, the Permanent Fund, and others to withhold the paying parent’s income or assets; 
 attach IRS tax refunds to collect child support; and 
 provide interstate services when parents move to other states. 
 enforce medical support orders. 
 
There is no fee for these services, although the costs of determining paternity may be charged to the father.  
CSSD cannot monitor or modify visitation or custody orders; a court must address those matters. 
 
 
Child Support Payments 
Support orders established by CSSD begin with the month CSSD receives the application, unless the children 
received public assistance earlier.  Once CSSD receives an application, all support payments must be made 
through CSSD unless a court order provides otherwise.  If a custodian receives a direct payment before the case 
is set up, the custodian must tell CSSD, in writing, how much was received and when.  Money collected by 
CSSD is paid to the custodian, unless the custodian or the child is receiving or has received public assistance.  
In those cases, the state debt must be repaid. 
 
 
Establishing Paternity 
If paternity has not been established and child support is requested, CSSD will establish paternity.  This 
generally occurs when a child is born to unmarried parents.  If the child was born in Alaska, parents can contact 
the Bureau of Vital Statistics to complete an affidavit if they agree about paternity.  If the child was born in 
another state, they must contact that state for assistance.  If they disagree, CSSD will require genetic tests to 
determine paternity. The man who proves to be the biological father may be required to pay for genetic tests and 
related costs.

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 3 of 12 
 
Establishing Support Orders 
CSSD calculates child support using the Child Support Guidelines in Alaska Supreme Court Rule of Civil 
Procedure 90.3.  This rule requires that the child support obligation be a percentage of the adjusted annual 
income of the non custodial parent based on the number of children in the support order.  Parties can ask for 
exceptions.  If a parent does not provide income information, CSSD will use the best information available to 
determine the parent’s income from all sources.   
 
We use an “Administrative Child Support Order” when we issue a child support or medical support order.  
Either party can appeal the findings in that order and present evidence.  After an administrative review, we may 
change those findings.  Either party may appeal the CSSD decision to the Office of Administrative Hearings 
Administrative Law Judge. Either party may then appeal the Administrative Law Judge’s decision to the 
superior court. 
 
Enforcing Support Orders 
If child support is owed and CSSD identifies the non custodial parent’s employer, bank account, or other 
financial account, we normally issue an Order to Withhold and Deliver those wages or assets.  The withholding 
order is a standard method of ensuring timely support payments.  Support is withheld directly from the payroll 
office or the bank account.  Non custodial parents who want to make additional payments, or who are self-
employed, may pay by check or money order.  Please include the case number with the payment, and send it to 
the payment mailing address (see the cover sheet of this application).  Cash payments can be made only in 
person, and only in Anchorage.  
 
Failure to pay support may result in collection actions including liens, judgments, withholding from Permanent 
Fund Dividends, wages, or other income, credit bureau reporting, the seizure of bank and financial accounts, 
and other civil and criminal law actions.  Non custodial parents who owe more than four months of child 
support may lose their occupational licenses or their driver’s licenses.  Non custodial parents who owe $2,500 
or more in past child support (arrears) risk losing their passports.  We file liens on real estate if arrears are at 
least $2,500 or equal to one year’s support.  CSSD may take the non custodial parent’s federal income tax 
refunds to pay arrears.  If the custodian received public assistance in Alaska, the IRS refund is applied first to 
reimburse the state.  IRS funds remaining after the state is paid go to the custodian.  
 
Modifying Support Orders 
Either party, or the state, has the right to request a review of a child support order.  Both parties must provide 
financial information to CSSD.  Private agreements between parties are not valid unless approved by the court.  
Situations that could result in support modification are:	
  	
 a child listed in the order has reached the age of majority or been legally emancipated; 
 the child support guidelines were adopted or significantly amended after the support order was issued; 
 the obligor’s income has changed to the extent that support would change by 15 percent; or 
 medical support or post-majority support language is needed in the order. 
 
If a court issues a support order, usually the court must modify the order.  If CSSD or another child support 
agency issues an administrative support order, the agency can modify it. 
 
Your Rights and Responsibilities 
Alaska law allows interest to be charged on payments received ten or more days past the due date, on 
judgments, and on most arrears.   
 
If you use CSSD services, you must notify us immediately of the following: 
 address changes, new employment, or changes in earnings; 
 permanent custody changes;

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 4 of 12 
 
 visitation when there is a court order for visitation; 
 payments received directly from the non custodial parent; 
 availability of or changes in health care coverage for the children; 
 any action by the parties that may affect support (such as seeking a new or modified court order, custody 
changes, adoptions, bankruptcy, or other collections). 
 
We invite parties to attend and participate in case proceedings and hearings to protect their interests.  An 
Assistant Attorney General represents CSSD in child support hearings; parties may hire attorneys at their own 
expense.  
 
Medical Support 
Federal and state laws require parents to provide medical support for their minor children.  CSSD will provide 
medical support services to the applicant.  Those services will include establishment, modification and 
enforcement of support orders that include health insurance provisions and cash medical support, in addition to 
regular child support. Credit for health care coverage may raise or lower the amount of ongoing child support, 
depending on which parent provides the coverage.  Health insurance benefits available through the Indian 
Health Service or the military may satisfy the medical support requirement.  Custodians who receive only 
Medicaid must assign to the state their medical insurance benefits or any fixed amounts of cash medical support 
the non-custodial parent is ordered to pay. 
 
Public Assistance 
If the custodian receives public assistance through ATAP (the Alaska Temporary Assistance Program, which 
replaced AFDC), through another state’s welfare program (such as those funded through TANF, the federal 
Temporary Aid for Needy Families program) or through Medicaid or Denali KidCare, we automatically provide 
services without requiring a CSSD application.  In ATAP or TANF cases, child support must be assigned to the 
state. This means the state will keep the child support received up to the amount of public assistance paid out. 
Enforcement cannot stop while public assistance is being received, while the children are in licensed foster care, 
or if the other party applies for services.  If the custodian receives only Medicaid or Denali KidCare and does 
not want cash support, CSSD must be notified.  We will continue to enforce only the medical support order.  If 
all public assistance ends, CSSD services will stop upon the custodian’s written request, although enforcement 
to recover money owed to the state may continue. 
 
Requesting Confidentiality	 
The Child Support Services Division may be required to release information about you or your children to other 
parties or agencies.  Information that may be released may include names, addresses, social security numbers, 
and birth dates.  This information will be released only when authorized by law and only as needed to take 
action on your case.  This information will not be released to the general public.  However, if your case is filed 
in court, information in the court case may be available to the public.    	
 
If you or your children have been victims of domestic violence, including harassment, threats, mental or 
emotional abuse, physical violence including sexual assault or incest, and parental kidnapping, you may 
ask that information about your address and location be kept confidential.   
 
You must complete the “Affidavit and Request for Address Confidentiality” on page 11, sign it before a notary 
or a witness, and return it within 30 days.  Attach any documents you have (such as police reports, protective 
orders, restraining orders, or medical records) to show why you believe the release of information about your 
address or your location would threaten your well being.  We will review your request and get back to you in 
writing.  Please contact us if you have questions.  The CSSD addresses and phone numbers are on the cover 
sheet of this application.

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 5 of 12 
   
 	
 	
 	
APPLICATION FOR CHILD SUPPORT SERVICES 	
 
Please indicate which services you want.  You must provide all information necessary for these services. Attach 
complete copies of orders or documents relating to custody, support and paternity. DO NOT SEND ORIGINALS. 
 
 	
 Support order establishment 	 Paternity establishment  	 Medical support order establishment 
 	
 Enforcement of an existing order 	 Review, modification, and enforcement of an existing order	 
 
 	
 
Full name__________________________________   Birth/previous/other names _______________________________ 
Date of Birth _______________ Birthplace ________________________________  SSN ________________________  
Mailing address  _____________________________________City____________________ State ____ Zip __________ 
Home address _______________________________________ City____________________ State ____ Zip __________ 
Driver’s license state and # _________________Home phone ________________Email address ___________________  
Employer____________________________________Work phone _________________  Work hours _______________	
 	
Does an attorney represent you in any matters related to the child or the other parent? 	   	 Yes    	 No     If yes, provide 
the attorney’s name, address, and phone	
 __________________________________________________________ 	
Have you ever received public assistance such as ATAP (Alaska Temporary Assistance), TANF (Temporary Aid to 
Needy Families), AFDC, or Medicaid?  	
 Yes   	 No   If yes, indicate what type, when, in what state, and provide a case 
number if available  _________________________________________________________________________________ 	
 
 
 
Child’s full name  Sex  Date and place of birth  SSN  Who does this child live with? 
     
     
     
     
 
You are the 	
mother  	father  	relative __________ 	 	 legal custodian by court order (explain)__________________	 
 	
 
 
Full name ______________________________________  Birth/previous/other names  ___________________________ 
Date of Birth _________________ Birthplace ________________________________ SSN _______________________  
Address      	
Current  	Last known      _________________________________________________________________ 
City_________________________ State _____ Zip __________ Driver’s license state and # ______________________ 
Home phone _________________ Email _________________   Citizen of  	
 U.S.  	 other country ________________ 
 	
 For office use only:  Requested: ___________  Sent: ___________ Case #: ___________________________                        Date                                Date                              Reinstatement/Existing/Other     	
INFORMATION ABOUT YOU (THE APPLICANT)	   PLEASE PRINT 	
CHILDREN YOU ARE SEEKING SUPPORT FOR (add pages if necessary) 	
NONCUSTODIAL PARENT YOU ARE SEEKING SUPPORT FROM

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 6 of 12 
 
How is the person related to the child? __________________________________________________________________ 
Height ______Weight  _____  Hair color  _____Eye color ______ Race__________  Marks, scars, tattoos____________ 
Does/did the person live or work in Alaska? 	
Yes  	No    If yes, where and when? _____________________________  
Does the person have relatives in Alaska?  Who and where? _________________________________________________ 
Usual occupation __________________________ Union member?  (name and local number) ______________________ 
 	
Current or most recent employer(s)  Employer address  Employer phone  Dates of employment 	
     
     
     
 
Military Service:  	
None             	Active                 	Reserve                	Guard                  	Retired    
                Branch/unit ______________________ Last rank/grade _______________ Yrs in service __________ 
Tribal or Alaska Native corporation member?  	
Yes 	 No     If yes, which corporation?  _________________________ 
Does this person have an attorney regarding child support? 	
No  	Yes   Who?	 ______________________________	 
Does or did the person receive (or does the person expect future) cash gifts, settlements, or awards? _________________ 
_________________________________________________________________________________________________ 
Other information that may be helpful in obtaining support (for example, bank accounts, stocks, property, pension, or 
other sources of income) ____________________________________________________________________________ 
 
 	
 
 
 Divorced                                        Date of separation  _____________________  Date of divorce _________________  
  Court case number  ________________________________ 
          City/County/State__________________________________ 
  Attach a complete copy of the divorce decree/order. 
                                               
 Married but separated   Marriage date/place ___________________  Separation date ___________________ 
 
 Divorce/Dissolution pending         Date filed  _____________________   Separation date _______________________ 
       City/County/State_____________________ Court case number_________________ 
 
 Never married                     Separation date (if parents lived together) _________________________________ 
                                                                      Complete the following.  Attach a birth certificate for each child.    
           
  Child: _____________   Did the father sign an Affidavit of Paternity?   	
 Yes 	 No 
                                  Is the father’s name on the birth certificate?     	
 Yes  	 No* 
                               In what state was the birth certificate issued?  _______________ 
      Child: _____________   Did the father sign an Affidavit of Paternity?   	
 Yes  	 No 
                                  Is the father’s name on the birth certificate?     	
 Yes  	 No* 
                                 In what state was the birth certificate issued?  _______________ 
  Child: _____________   Did the father sign an Affidavit of Paternity?   	
 Yes  	 No 
                                 Is the father’s name on the birth certificate?     	
 Yes  	 No* 
                                 In what state was the birth certificate issued?  _______________	
 	
*If no, complete page 12 	
 Other (explain) __________________________________________________________________________________ 	
RELATIONSHIP BETWEEN THE PARENTS

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 7 of 12 
 
 
 
   Check here if you have been a victim of domestic violence and you want your address to be kept confidential from the 
other party.  Please submit an “Affidavit and Request for Address Confidentiality” (see page 11). 
 
   Check here if you agree that if CSSD sends a child support payment to you in error, you want to repay the 
overpayment gradually out of future child support payments (instead of immediately in a lump sum).  CSSD will 
provide child support services to you even if you don’t agree to repay overpayments from future payments. 
 
  Check here if you have or have had a child support case in Alaska or another state, and explain: For which child? 
________________  In what state/county? ______________ Do you know the case number? ___________________ 
 
 Check here if the child is eligible for Indian Health Service, military, or other health care coverage, and explain: Which 
child? ______________________ Eligibility through which parent? ______________________________________   
      Type of coverage? ______________________________________________________________________________ 
 
Include a complete copy of all orders relating to custody, support, and paternity. 
Do not send original documents. 
Complete the Statement of Support Received even if you receive no support. 
Complete the confidentiality affidavit if you want your address withheld from the other party.	
 	
Your signature is required before CSSD can process this case. 	
 
Applicant's signature: ________________________________________      Date: _____________________ 
 
Return the completed application, the statement of support received, the confidentiality affidavit (if needed) and all 
supporting documents to: 
 
Child Support Services Division 
550 W 7	
th Avenue   Suite 310    
Anchorage AK 99501-6699	
 	
OTHER INFORMATION

CSSD 04-1017 (Rev. 01/03/12)  (12 pp.)                 Custodian’s Application for Services     Page 8 of 12 
   
 	
Instructions for Completing the Statement of Support Received 	
 
1.   Enter your name and the non custodial parent’s name.  Include the CSSD case number if you have a case already.  
 
2.   Enter the full name and date of birth for each child in your custody.  
 
3.   If there is an administrative support order from Alaska or another state, check the first option.  If there is a court 
order, check the second option, and indicate whether the court order includes child support, alimony (spousal 
support), or both.  If there is both a court order and an administrative order, check both the first and second 
options.  If there is no order of any kind, check the third option.  
 
4.   If you have received child support from the non custodial parent, check the first option and complete the “Child 
Support” column in the table on the bottom of the page.  Don’t forget to indicate the year(s).  See example below.  
If you have received some child support, but you are not sure when or how much, check the second option and 
enter your estimates in the table (marked “estimates”) or on a separate page.  If you have received no child support 
at any time, check the third option.   
 
NOTE:  If the custodial parent or the child is receiving government benefits from Social Security, the Veterans 
Administration, or another government agency, and the benefits are based on the non custodial parent’s disability 
or retirement, these benefits may be credited toward the non custodial parent’s support obligation.  Please provide 
information about such benefits on a separate page. 
 
5. If you have received alimony or spousal support from the non custodial parent, check the first option and complete 
the “Alimony/Spousal” column in the table.  Don’t forget to indicate the year(s). See example below.  If you have 
received some spousal support, but you are not sure when or how much, check the second option and enter your 
estimates in the table (marked “estimates”) or on a separate page.  If you have received no alimony or spousal 
support at any time, check the third option. 
 
6. If a child support order is already in effect, and you lived with the other parent or the other parent had custody of 
the child at any time since the child support order took effect, please check the “Yes” box and attach a written 
explanation  
 
Table: Enter only the support you have received in this table.  Do not enter support owed.  Start your entries with the 
first month and year you were supposed to receive support, and continue through the current month and year.  Enter 
“0” in months when support was due but no support was received.  Add additional pages, if necessary.   
 
For example, if the child support order says you should have received $250 child support per month beginning in June 
of 2000, and no spousal support, and the custodial parent paid irregularly and never paid the full monthly child support 
amount, your “support received” table might look like this in December 2001:	
 
      	
 	
  Year 
2000 Child 
Support Alimony/  
Spousal  Year 
2001 Child 
Support Alimony/ 
Spousal 	
      Jan 	N/A N/A  	Jan 	$0 N/A 	   
 Feb 	   	Feb 	$75  	   
 Ma	r 	   	Mar 	$50  	   
 A	pr 	   	Apr 	$0  	   
 Ma	y  	  	May 	$0  	   
 Jun 	$100   	Jun 	$75  	   
 Jul 	0   	Jul 	$175  	   
 Au	g 	$150   	Aug 	0  	   
 Se	p 	$150   	Sep 	0  	   
 Oct 	0   	Oct 	$200  	   
 Nov 	$225   	Nov 	$100  	   
 Dec 	$175   	Dec 	$0

1606  (CSSD 04-1017 Rev. 04/27/10)  (12 pp.)                 Custodian’s Application for Services     Page 9 of 12 
 
STATEMENT OF SUPPORT RECEIVED 	
 
See previous page for instructions.  If you received no support, please check “no support received” and sign the next page.	
 
 	
1.  Your name: ______________________ 	CSSD	 case # __________Non custodial parent’s name ______________________ 
 
 
2.  You are the custodian of these minor children: 
 	
Child’s full name    Date of birth Child’s full name   Date of birth
       
       	
       	
 
 
  Check the appropriate boxes in items 3-6, and complete the table below (or submit separate estimates, as necessary).   
 
3. 	
 An administrative order from 
CSSD	 or another child support 
agency directs that you are 
entitled to receive child support.  
OR 	
 A court order directs that you are 
entitled to receive 	
 
          	
 child support	 
          	
  alimony 	(spousal support)  
 OR 	
 No administrative or court 
order for child support is in 
effect at this time. 	
 	
4. 	 List in the table below the 
child support payments you have 
received directly from the non 
custodial parent.  Don’t forget to 
indicate the year.   
OR 	 If you aren’t sure how much 
child support you’ve received from 
the non custodial parent, list your 
best estimate by month and year in 
the table below (or on a separate 
page)	
  
 	
OR 	
  You have received no 
child support from the non 
custodial parent.	
 	
 
5. 	
   List in the table below the 
alimony (spousal support) you 
have received directly from the 
non custodial parent.  Don’t 
forget to indicate the year.  
OR 
  
 	 If you aren’t sure how much 
alimony (spousal support) you’ve 
received from the non custodial 
parent, list your best estimate by 
month and year in the table below 
(or on a separate page)  
 OR 	 You have received no 
alimony (spousal support) 
from the non custodial 
parent. 
                                            
    	
                                        
6.  If a child support order is already in effect, did you live with the other parent (or has the other parent had custody of the 
children) at any time since that order was issued?   	
 Yes   	 No    If your answer is “Yes,” attach a description of the time 
periods when you lived together (or when the other parent had custody) since the child support order was issued. 
 	
Enter only support received in the following table.  Do not enter support due. 	
Year: Child Support 
 Alimony/ 
S	
pousal  
Year: Child Support  Alimony/ 
S	pousal 
Year: Child Support  Alimony/ 
S	pousal	
Jan 	  
 	Jan 	  	Jan 	  	
Feb 	   	Feb 	   	Feb 	  	
Mar 	   	Mar 	   	Mar 	  	
Apr 	   	Apr 	   	Apr 	  	
May 	   	May 	   	May 	  	
Jun 	   	Jun 	   	Jun 	  	
July 	   	July 	   	July 	  	
Aug 	   	Aug 	   	Aug 	  	
Sep 	   	Sep 	   	Sep 	  	
Oct 	   	Oct 	   	Oct 	  	
Nov 	   	Nov 	   	Nov 	  	
Dec 	   	Dec 	   	Dec 	  	
                                                                                          
(Continued on the next page, where your signature is required.)

1606  (CSSD 04-1017 Rev. 04/27/10)  (12 pp.)                 Custodian’s Application for Services     Page 10 of 12 
 
Statement of Support Received continued 
 	
Year: 	Child Support 
 Alimony/ 
S	
pousal 	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
Jan 	  
 	Jan 	  	Jan 	  	
Feb 	   	Feb 	   	Feb 	  	
Mar 	   	Mar 	   	Mar 	  	
Apr 	   	Apr 	   	Apr 	  	
May 	   	May 	   	May 	  	
Jun 	   	Jun 	   	Jun 	  	
July 	   	July 	   	July 	  	
Aug 	   	Aug 	   	Aug 	  	
Sep 	   	Sep 	   	Sep 	  	
Oct 	   	Oct 	   	Oct 	  	
Nov 	   	Nov 	   	Nov 	  	
Dec 	   	Dec 	   	Dec 	  	
  	
Year: 	Child Support 
 Alimony/ 
S	
pousal 	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
Jan 	  
 	Jan 	  	Jan 	  	
Feb 	   	Feb 	   	Feb 	  	
Mar 	   	Mar 	   	Mar 	  	
Apr 	   	Apr 	   	Apr 	  	
May 	   	May 	   	May 	  	
Jun 	   	Jun 	   	Jun 	  	
July 	   	July 	   	July 	  	
Aug 	   	Aug 	   	Aug 	  	
Sep 	   	Sep 	   	Sep 	  	
Oct 	   	Oct 	   	Oct 	  	
Nov 	   	Nov 	   	Nov 	  	
Dec 	   	Dec 	   	Dec 	  	
  	
Year: 	Child Support 
 Alimony/ 
S	
pousal 	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
 
Year: 	Child Support  Alimony/ 
S	
pousal	
Jan 	  
 	Jan 	  	Jan 	  	
Feb 	   	Feb 	   	Feb 	  	
Mar 	   	Mar 	   	Mar 	  	
Apr 	   	Apr 	   	Apr 	  	
May 	   	May 	   	May 	  	
Jun 	   	Jun 	   	Jun 	  	
July 	   	July 	   	July 	  	
Aug 	   	Aug 	   	Aug 	  	
Sep 	   	Sep 	   	Sep 	  	
Oct 	   	Oct 	   	Oct 	  	
Nov 	   	Nov 	   	Nov 	  	
Dec 	   	Dec 	   	Dec 	  	
 
 
  
            Signature 	
__________________________________                                                                Date ____________________

0502  (CSSD 04-1017 Rev. 04/27/10)  (12 pp.)                 Custodian’s Application for Services     Page 11 of 12 	
Affidavit and Request for Nondisclosure of Identifying Information 	
 	
Complete this affidavit only if you want your address and information about your location to be kept confidential and not 
released to a person (such as a parent or custodian) who would otherwise be entitled to have the information.  CSSD 
will respond in writing with a decision about your request for confidentiality. 
 
I, ______________________________________________, swear under penalty of perjury that the following information 
is true to the best of my knowledge and belief: 
 
Name of person I do not want information released to: __________________________ 
Person’s relationship to me or the child: __________________   
CSSD case number: _____________ 
 
Please check all that apply: 
 	
   1.  This person has committed domestic violence (threatened, harassed, physically or mentally abused, or committed 
sexual assault or incest) against me or my child. 
 
    2.  A domestic restraining or violence protective order has been issued against the person. 
 
    3.  The person has been charged with a crime (such as assault or harassment) or been involved in a criminal civil or 
criminal court case in which I was a party, a victim, a witness, or otherwise involved. 
 
If you checked any of the above please explain what happened, when, where and who was involved. 	
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ 
 
If you checked # 2 or 3, please indicate the Court location and case number:_______________________    
 
If you did not check any of the boxes above, please explain why you feel threatened by this person.	 
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ 
____________________________________________________________________________________________________________ 
 
If you need additional space for your answers, please use the back of this page. 	
 
 	
Signature ______________________________    Date__________________________ 
  	
 
SUBSCRIBED and SWORN to before me this _________ day of _______________________, 20 ______ 
 
  ___________________________________________ 
        Notary Public for the State of  ______________ 
             My commission expires ___________________ 
 
 
If you can’t get to a notary, please sign before a witness and have the witness complete the information below. 	
 	
I know the person who signed this form is the person he or she claims to be, and I witnessed the signature above. 
 
Witness signature  _______________________________   Witness name (please print) __________________________________  
Witness address _______________________________________________Witness phone ________________________________ 
 
 	
CSSD MAILING ADDRESS:       550 W 7	th AVE SUITE 310      ANCHORAGE AK        99501-6699

1604D  (CSSD 04-1017 Rev. 04/27/10)  (12 pp.)                 Custodian’s Application for Services     Page 12 of 12 
 	
 
PATERNITY WITNESS STATEMENT 
 	
CSSD	 Case No:  __________________________ 
 
A separate statement is required for each child whose paternity must be established 
(use the back of the form for detailed explanations)  
  
I, ____________________,  am the natural mother of (child’s name - first, middle, last) ___________________________________     
 
Child’s date of birth  __________     	
Male   	Female     Child’s place of birth (city, county, state) ________________________ 
 
a.  Date of conception  (month, date, year) ______________  City, county, state where conception occurred: ___________________ 
 
b.  Full term pregnancy? 	
Yes  	No   If no, explain:   ___________________________________________________________ 
 
c.  The child was conceived as a result of sexual intercourse between ______________________and me during the time stated above. 
 
d.  A man is named as the father on the child’s birth certificate. 	
 Yes (attach copy) 	 No    If yes, provide his name and address:   
_______________________________________________________________________________________________________ 
 
e.  I was married at the time of this child’s birth. 	
 Yes  	  No       If yes, complete the following: 
 
Husband’s name (first, middle, last) and last known address:  ________________________________________________ 
 _________________________________________________________________________________________________ 
 
State why husband is not the father of this child and attach all appropriate documents, including divorce decree, test results, 
and prior findings of non paternity, if any: ________________________________________________________________ 
_________________________________________________________________________________________________ 
 
f.    Genetic tests were completed to determine the father of the child. 	
 Yes      	  No   If yes, attach results, explain outcome, and 
list name(s) and address(es) of the man or men tested: ___________________________________________________________ 
       _______________________________________________________________________________________________________ 
 
g.    I had sexual intercourse with another man or men (other than the man I am naming as the child’s natural father) during the time 
30 days before or 30 days after the child was conceived  	
 Yes  	  No    If yes, complete the following:   
 
Name and address of other man/men: ___________________________________________________________________ 
 
The other man/men are biologically related to the man I am naming as the child’s natural father. 	
Yes     	 No    If yes, 
state the biological relationship (e.g., brother, cousin, uncle, etc.) _______________________________________________ 
 
I do not believe the other man/men is/are the father because ____________________________________________________ 
____________________________________________________________________________________________________ 
  
 
All the information and facts contained in this Paternity Witness Statement are true and correct to the best of my knowledge 
and belief.  I agree to submit myself and my child, if I am the custodian, to genetic testing when necessary to establish 
paternity. 
 
Signature of mother _____________________________________        Date   ____________________ 
    
        
 
Statement of witness to mother’s signature 
 
I willingly state that I know _________________________,  who signed this form, and I witnessed her signature above. 
Signature of witness   __________________________________      Date  _________________________________________  
Printed name of witness ________________________________  Telephone number of witness _______________________ 
Address of witness   _______________________________________________________________________________________
Relevant article from our knowledge database

The net has become a vital propagator of knowledge, both through free in addition to paid services. It has been mankind's greatest means of communication yet. Also, a number of these services have been shown to be helpful in locating some missing people within the past. You will need to verify that you are not able to cover attorney services and fill out an application.
Read more

If parents cannot agree on custody and visitation, they're also able to ask the court to appoint a mental wellness expert like a psychologist to perform a custody evaluation. They can be assured that an urgent message will be delivered once you get access to your phone. They often get defensive while speaking about their child's food habits. They should take into account their children's age, personality and experiences.

The program gives educational material on the significance of healthful diet, staying physically active, and the way to plan your financial plan for the entire month. Clearly, you may always have a look at government programs for temporary help too. You may take a look at government assistance programs in your town for aid.

Should you need help paying for Christmas, here's a massive collection of charities that will help you. People around us can require help at any instance of the day. If this is so, you might be able to register for help from these types of groups. There's even additional aid for energy costs known as the heating and cooling bills.

Next: Alabama Notice of Entry of Judgment of Divorce Form Previous: Alaska Information About Mediation Form
If you want to remove Application for Child Support Services from this website please contact us providing the reasons together with this url: https://formsarchive.com/application-for-child-support-services/

Leave a Reply

Your email address will not be published. Required fields are marked *

You can use these HTML tags and attributes <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>