West Virginia Child Support Enforcement and Income Witholding Form

Through the information reflected in this form, the Court decides whether spousal or child support payments should be collected from a certain spouse after the finalization of the divorce.Download

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BUREAU FOR CHILD SUPPORT ENFORCEMENT
	
APPLICATION AND INCOME WITHHOLDING FORM
	
This Form MUST Be Completed In All Cases Involving Minor Children or Spo\
usal Support! 	
County: _________________________ Civil Action No.  ____________ 	
Withholding services will begin immediately when the Bureau for Child Support Enforcement 
receives this completed application, which MUST  be accompanied by a copy of the current 
Support Order IF one is now in effect. 
___  Check this blank if a Support Order is NOW in effect. 
Petitioner	   Full Name: _________________________ Birth date: _______ SSN: ___________ 
Sex: _____  Relationship to children involved in this case: ________________________\
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Residence Address: _____________________________________________________\
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(List complete  physical address: county; city;  street #; apt. #; zip code.	) 
Mailing Address: _______________________________________________________\
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(List mailing address ONLY if different from physical address.	) 
Daytime phone #: ____________________   Driver’s License #: ______________________ 	
Respondent	   Full Name: _________________________ Birth date: _______ SSN: ___________ 
Sex: _____  Relationship to children involved in this case: ________________________\
_______ 	
Residence Address: _____________________________________________________\
________ 	
(List complete  physical address: county; city;  street #; apt. #; zip code.	) 
Mailing Address: _______________________________________________________\
______ 	
(List mailing address ONLY if different from physical address.	) 	
Daytime phone #: ____________________   Driver’s License #: ______________________ 
Dependents 	( List full name; sex; birth date; social security #; and custodian for each dependent.)\
 	
Income Withholding 	(List complete  address of the employer or  other source of income to which an Income 
Withholding Notice should be sent.	
) 	
Check this blank if YOU WOULD FE AR FOR YOUR SAFETY, or THE SAFETY OF 
YOUR CHILDREN if your address and telephone number are disclosed. 
Check this blank if you currently receive TANF benefits. 	
CONTINUE ON NEXT PAGE 
SCA-FC-113  (12/01)  Bureau for Child Support Enforcement Application  Page 1 of 2

___ Check this blank if you or one of your children currently receives a DHH\
S Medical Card. 
___ 
Check this blank if you currently receive, or have applied for DHHS Chil\
d Support Services. 
IF YOU CHECKED any of the four items immediat ely above, skip to the end of the form, SIGN 
on the line provided, and you are done. 
IF YOU DID NOT CHECK any of the four items immediately above, YOU MUST CONTINUE! 
___	I understand that unless otherwise directed by the court, any court orde\
red support MUST be 
collected by the BCSE through Income Withholding. 
YOU MUST  CHOOSE ONE OF THE THREE FOLLOWING OPTIONS! 
OPTION # 1. 
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I am applying for FULL SERVICES from the BCSE.  I understand that full services include, 
but are not limited to the following: *Collection and distribution of support payments. 
*Collection and enforcement of support by income withholding.  *Establishment and 
enforcement of Support Orders.  *Establishment  of paternity.  *Enforcement of Support Orders 
through Federal and State Tax offsets, unemployment compensation intercepts, and workers’ 
compensation intercepts.  *Location of parent(s).  *Interstate services. 
___	 As an applicant for FULL SERVICES, I AGREE to comply with the following requirements: 	
1. 	I understand I MUST assist the BCSE to establish and enforce paternity, \
child support, and 
medical support, and to collect child and spousal support.  I understand \
this assistance may 
include providing information about the non-custodial parent, and responding promptly and 
completely to requests from the BCSE.  I understand I may be required to testify as a witness in 
court, or in other proceedings. 	
2. 	I understand that I am free to pursue legal actions through a private lawyer, but that I must 
inform the BCSE if I do this. 	
3. 	I understand that I MUST repay all money received in error to which I am not entitled. 	
OPTION # 2. 
___	 I am applying for Income Withholding Services ONLY. 
OPTION # 3. 
___ I DID NOT CHECK Option #1 or Option #2.  I do not want services from the BCSE at this 	
time	. 
___  I understand that even though I have not requested services at this time, I can request services 
at any time by applying at the BCSE office in the county in which I live. 	
I CERTIFY that I have read and understand all stat ements on this application, and that all 
information I have provided is TRUE and ACCURATE to the best of my knowledge. 	
Signature: _______________________________________________  Date: ________________ 
SCA-FC-113  (12/01)  Bureau for Child Support Enforcement Application	 Page 2 of 2