KLAMATH TRIBES JUDICIARY

CHILD SUPPORT ENFORCEMENT OFFICE

Application for Child Support Services

Office Use Only:
Date Requested:______Date Received:______CSE #______
Section 1
Please mark all that apply
This is my first application for support services from any Agency.
I was referred by TANF.
I am or the child(ren) is receiving Public Assistance from the State of Oregon.
I am re-opening my case with the Child Support Enforcement Office.
There is a case filed elsewhere and I am seeking the assistance of the Child Support
Enforcement Office in transferring my case.

Where filed:______

Case #:______

Section 2
  1. Custodial Parent: This section is about the person with whom the child(ren) actually live.

Full Legal Name: Last First Middle / Other Names Used:
Date of Birth: / Social Security Number: / Sex: M / F
Race: / If Native American, what tribe? Enrollment #
What is the relationship of the custodial parent to the child(ren) (Birth Mother, Grandmother)?
Mailing Address City State Zip Code
Physical Address: City State Zip Code
County of Residence: / Home Phone Number:
Section 3
1. Custodial Parent’sChild(ren): (Name all Children):
Child(ren)s Name / Date of Birth / Enrollment
Tribe & # / Social Security Number / Child of Both Parties Listed (Y/N) / Seeking SupportFor This Child (Y/N)

Is paternity established for the above named child(ren)? If so which ones: ______

______

I am seeking paternity establishment for the following child(ren): ______

______

(Allegation of Paternity paperwork attached)

Have you ever been on Public Assistance whether it was with a State or Tribe Yes No

If yes, where did you receive the Public Assistance from: ______

Section 4
  1. List Below All Employment Present And Past(start with most recent work experience and continue back for the past 5 years). Include any military service, self-employment, unemployment, and all paid experience.

Name of Company / Address / Start Date / End Date / Occupation / Hours Per Week / Hourly Income
Section 5

1.Information for the Non-Custodial Parent

A. Non-Custodial Parent you are seeking child support from: (this section is about the person the child does not live with)

Full Legal Name: Last First Middle / Other Names Used:
Date of Birth: / Social Security Number: / Sex: M / F / Drivers License Number:
Race: / If Native American, what tribe? Enrollment #
Mailing Address: City State Zip Code
Physical Address: City State Zip Code
County of Residence: / Home Phone Number:

B.List the Addresses of the Non-Custodial Parent for the last two years

Address / County / From / To

C.List the last five years of known Employment for the Non-Custodial Parent:

Name of Company / Address / Start Date / End
Date / Occupation / Hours
Per Week / Hourly Income
  1. Military Service:

Is the Non-Custodial Parent currently or previously a member of the armed services? Y/N______

If the Non-Custodial Parent was/is a member of the armed services, which branch? ______

What dates was the Non-Custodial Parent enlisted in the armed services? ______

Please List Identifying Information:

Height / Weight / Hair Color / Eye color
Identifying Marks (tattoos, scars, etc)
Section 6
1.Additional Information:
Check here if you have been a victim of domestic violence and you want your address to be kept confidential.
Check here if you fear the safety of you or your child(ren) if your address is not kept confidential.

* If you checked either of the above boxes please fill out the Affidavit and Request for Nondisclosure of Information form.

Check here if your child(ren) is eligible for health service through Indian Health Services, military health service,
or other health services.

Which Child? ______Eligibility through which Parent? ______

Type of Coverage? ______

Policy number?______

KLAMATH TRIBES JUDICIARY

CHILD SUPPORT ENFORCEMENT OFFICE

Application for Child Support Services
Statement of Agreement

I agree and understand that the Child Support Enforcement Office (CSE) is going to act in the best interests of the taxpayers, the tribe and the child(ren). I understand that the Child Support Enforcement Office does not have the same confidentiality relationship with me that a private attorney would. I understand that confidential information will not be released to the general public, but instead will be used to gather support from the other parent(s). I consent to the Child Support Enforcement Office releasing the necessary information in an effort to collect support.

I understand that the CSE Office does not represent me. I understand that CSE Office is providing a service in an attempt to receive support for my child (ren), and the CSE Office cannot give me legal advice. For legal advice, I need to consult an attorney on my own accord.

I agree and understand that the CSE Office will through diligent effort attempt to collect all child support, however they cannot guarantee that I will receive the child support awarded to me.

I agree that the CSE Office will collect any money that is owed to the tribe or to the state for TANF services, which my child(ren) benefitted from. I also agree that any amounts over the TANF reimbursement will be issued to me.

I agree to reimburse the tribe immediately if for any reason I have received an overpayment, and failure to reimburse will result in my child support payments being garnished and my taxes being intercepted.

I agree that I am to give the CSE Office all information as to payments paid directly to me; failure to do so may result in my case being closed.

I agree that for purposes of collection the CSE Office has the right to refer my case to the State of Oregon for collection of Federal Tax Offset. I further agree the CSE Office has the right to send all pertinent information to the State for this purpose.

I agree to all the terms above. I understand that a violation of the above agreements or failure to cooperate fully can result in the closure of my case. I swear and affirm that the information contained in this Application for Support Services is true to the best of my knowledge.

Applicant’s Signature: ______Date: ______

CIAS-01Application for Child Support Services Final 10-30-08