RFP 603

DHS/CSA 980/980A (Revised 0 7/17) 1 INSTRUCTIONS MARYLAND DEPARTMENT OF HUMAN SERVICES Child Support Administration If you prefer you may complete this form online at http://dh s.maryland.gov/child -support -services/ Form No.: DHS /CSA 980/980A Form Name: Application for Support Services Purpose: The purpose of this form is to gather information from the individual applying for child support services. Instructions: Complete Sections I, II, III, IV and V I. Child S upport person nel shall complete Sections VII and VI II. SECTION I : CUSTODIA L PARENT Provide all information requested. If “Family Violence is checked, provide corroborating evidence (e.g. police reports) or reason to believe that the disclosure of such data might result in physical or emotional harm to a custodial parent, noncus todial parent or a child in a case. NOTE: Corroborating evidence is not required. Indicating family violence will impact the quality of service provided by restricting the amount of information that can be shared with and obtained from the federal govern ment and other secure resources. SECTION II: SUPPORT - CHILDREN Provide all information requested. SECTION III: NONCUSTODIAL PARENT Provide most recent information. The DATE after LAST KNOWN ADDRESS refers to the latest date in which the information was known to be correct. SECTION IV: HEALTH INSURANCE If either parent has individual health insurance coverage or health insurance coverage for the child(ren), check the appropriate box and enter information about the insurance company, if known. SECTION V : LEGAL REPRESENTATION SECTION V I: PAYMENTS AND SIGNATURES After completing the required information the form must be signed by the applicant. SECTION VII: SERVICES REQUIRED To be completed by Child Support staff. SECTION VIII: VALIDATION The child support staff person shall check the appropriate box, sign the form, enter his/her title and the date of the validation Note: Some applicants will complete more than one application. In those instances, check “$15.00 application fee paid” on one form only. Check “Fee previously paid” on all others. ATTACHMENT : FINANCIAL STATEMENTS Provide all information requested. Distribution: Original – Case folder, 1 copy to applicant, 1 copy to Fiscal if accompanied by fee, 1 copy to prosecutor, if necess ary. DHS/CSA 980/980A (Revised 0 7/17) 2 INFORMATION FOR SUPPORT SERVICES Please complete this form carefully and provide as much detailed information as possible. Legibly print the answers on this form. If you are the custodial parent, complete a separate form for each noncustodial pare nt from whom you want support. The accuracy of the information you provide may affect how your case is handled. Disclosure of your Social Security number, and the Social Security number(s) of your child(ren), is required by federal law (42 USC 666(a)(13 )). The Child Support Administration will use these Social Security numbers only for the purpose of establishing and enforcing support for you and your family. If you do not understand any questions on this form, please call 1 -800-332-6347. SECTION I: C USTODIAL PARENT – (PARENT OR RELATIVE WITH WHOM THE CHILDREN RESIDE) __________________________________________ _________________________ ________________________ Full legal name (First, Middle, Last) Maiden Nam e Alias Name __________________________________________ ___________ ________________________ ____________ Address Sex Date of birth Race __________________________________________ __________________________ _______________________ City State Zip Code Social Security number Driver’s license number ___________________ _____________________ __________________________ ________________________ Home phone Business phone Pager/cell phone E -mail/web address __________________________________________ __________________________________________________ Employer’s name Employer’s address _________________________ _________________ ____________________________ ____________________ Name of nearest relative Relationship Phone number ________________________________________________________ _____________________________________ Address City State Zip Code □ Family Violence: I believe that disclosure of my a ddress or other identifying information might result in physical or emotional harm to me or my child. (Please see instructions on page 1.) □ I believe the other party (parent) will cooperate with this office to establish, modify and enforce a support order . □ I think the father will request genetic testing. SECTION II: SUPPORT – CHILDREN: Name Social Security Date of State and Sex Race Relationship State Where Number Birth Count y to you Conception Where Born Occurred 1)___________ _________ ____________ _ _______ ___________ ___ ___ _____________ ___________ 2)___________ _________ _____________ _______ ___________ ___ ___ _____________ ___________ 3)___________ ________ _ _____________ _______ ___________ ___ ___ _____________ ________ ___ 4)___________ _________ _____________ _______ ___________ ___ ___ _____________ ___________ 5)___________ _________ _____________ _______ ___________ ___ ___ _____________ ____________ DHS/CSA 980/980A (Revised 0 7/17) 3 1. If you are the biological mother of the child( ren), were you married to a man other than the noncustodial parent at the time the child(ren) were conceived or born?  Yes  No 2. What is your relationship to the noncustodial parent?  Never married  Currently ma rried  Separated  Divorced  Other ______________________ 3. Date married:__________ State where married:_________ Date/place divorced/separated:_________________ 4. If separated, have divorce proceedings been started by a private attorney and/or is court action currently pending?  Yes  No If yes, please list name, address, and phone number of the attorney and the County and State in which court action is pending: _________________ _________________________________________________________ __________________________________________________________________________________________ Is child support included in this action?  Yes  No 5. If the parents we re not married: Has paternity been established for the child(ren)?  Yes  No 6. Was an Affidavit of Parentage signed?  Yes  No If yes, which State? __________________ 7. Was paternity established by Court Order?  Yes  No If yes, which State? __________________ 8. If you answered YES to question #6 or 7 , please list the children for whom patern ity has been established or an Affidavit of Parentage signed: ____________________________________________ _______________________________________________ 9. Do you have a court order for child support from this noncustodial parent?  Yes  No 10. If you answered yes to #4, 5, 6, 7, 8 or 9 above, show where paternity/support was ordered. Inclu de a copy of the order with your application. __________________________ _________________ _________________________ ____________________ County State Court do cket # Date of order 11. Does the noncustodial parent pay support?  Yes  No 12. If yes or sometimes, to whom does the noncustodial parent pay support?  To you  To a child support agency  Other _____________________________________________ 13. Name and address of the child support agency: ____________________________________________________ __________________________________________________________________________________________ 14. Date support last paid: _____________________ Amount: $________________________________________ 15. Is support paid by a military allotment?  Yes  No 16. Have you ever received Temporary Cash Assistance (TCA, formerly AFDC or “welfare” ), Medical Assistance, or previously applied for Child Support Services?  Yes  No If yes, list the County and State: ______________________ Date of last TCA check if applicable: __________ 17. Date of the noncustodial parent’s last contact with applicant or child: ___________________________ DHS/CSA 980/980A (Revised 0 7/17) 4 SECTION III – NONCUSTODIAL PARENT (Parent from whom you want support) _________________________________________ ___________________ ______________ ________________ Full legal name (First, Middle, Last) Alias/Nickname Home phone Business pho ne _______________________ __________ _____ ________________________ __________________________ Date of birth Race Sex Social Security number Pager/cell phone number ______________________________________________________________ _______________________________ Address or l ast known address City State Zip Code Date _________________________________________ ____________ ____________ _____________ ___________ E-mail/web address Eyes Hair Height Weight Identification marks:____________________________________________________________________________ _________________________________ ______________________ ____ ____________________ ___________ Driver’s license number Automobile tag number Automobile make/model Year 1. Current or prior military service dates: From _________ to _________ What branch? _________________ 2. Has the noncustodial parent ever been in jail?  Yes  No Dates: From ___________ to ____________ Name of jail: ________________________ Address: _____________________________________________ 3. Noncustodial parent’s place of birth: _____________________________________________________________ 4. Is noncustodial parent a member of a Union/Local?  Yes  No If yes, please specify: _____________ 5. Name of nearest noncustodial relative: _______ _______________________________ Relationship _________ _____________________________________________________________________________________________ Address City State Zip Code 6. Name of noncustodial parent’s mother: __________________________________ Maiden name: ___________ ________________________________________________________________________________ ____ ________ Address City State Zip Code Phone number 7. Name of noncustodial parent’s father: _______________________________________________ _____________ ______________________________________________________________________________ ______________ Address City State Zip Code Phon e number 8. Noncustodial parent’s current or last known employer: ______________________________________________ Employer’s address: __________________________________________________________________________ Phone number: _______________ _____ Employment History – Dates: From ___________ to _____________ 9. Does noncustodial parent receive a pension, disability benefits, social security, or have any other source of income?  Yes  No  Unknown Income a mount: $ _____________ From what source: ____________________________________________ DHS/CSA 980/980A (Revised 0 7/17) 5 10. Does noncustodial parent have a license, certificate, registration or permit that is necessary to practice or work in a particular business, occupation or profession?  Yes  No If yes, what type? ___________________ 11. Does the noncustodial parent have other child support cases?  Yes  No  Unknown If yes, what State or States? ________________________ 12. Do you have a photograph of the noncustodial parent?  Yes  No If yes, please attach photograph. SECTION IV – HEALTH INSURANCE 1. Do the children have health insurance ?  Yes  No  Unknown 2. Insurance provided by  Mother  Father  Other (State, Stepparent, Grandparent, etc) Name/relationship of Other provider ______________________________ 3. Name, address, and phone number of health insurance company covering child(ren). ______________________ ___________ __________________________________________________________________________________ _____________________________________________________________________________________________ Policy number: _____________________ Group number: _______________ E ffective date: _____________ Policy expiration date: _________________________________ 4. Name and address of employer providing the health insurance. _______________________________________ _____________________________________________________ ________________________________________ 5. Name of child(ren) covered by the health insurance. ________________________________________________ _____________________________________________________________________________________________ 6. Type of c overage provided: (Check appropriate coverage)  HMO  PPO/PPN  POS  Pharmacy  Dental  Vision  Hospital services  Physician services  Other __________________ DHS/CSA 980/980A (Revised 0 7/17) 6 SECTION V : LEGAL REPR ESENTATION An attorney working in the Child Support program represents the Child Support Administration of the State of Maryland. The attorney does not represent you or your personal interest and there is no attorney -client relationship between you and the attorney, between you and the child support office, or any employees thereof. Any information you provide may not be treated as confidential, except as provided by law. You may be required to appear as a witness in court. Your failure to appear for court pursuant to an order or subpoena could result in your arrest. SECTION VI: PAYMENTS AND SIGNATURES Payments are applied to current support first, then arrears. If an obligor has more than one obligation, any payments collected by earnings withholding wil l be allocated among families in accordance with 45 CFR 303.100(a)(5). Fee Disclosure: I understand I may be required to pay a nonrefundable $15 application fee even if the agency does not succeed in getting support for the child(ren). A $15 annual user fee may be deducted from my support payment if collections exceed $3,500. Maryland’s Child Support Administration (CS A) disburses child support p ayments via Direct Deposit into your checking account. Y ou will be asked to complete a Direct Deposit applic ation form once your Child Support accounts are open. If you do not submit a Direct Deposit application when your accounts are opened, a Bank of America debit card will be issued to you. I understand that I will be required to return money sent to me in error . I understand that I can agree to have it taken incrementally from future payments by checking the box below . Failure to agree to have it taken out of future payments will not affect my application for services. I agree to reco upment from future payments. I am applying for support services on behalf of the child(ren) listed in this application. I personally have provided all information in this document. I furth er agree to notify my local MDCS A office immediately of any ch ange in my residential or mailing address, telephone number, income, expenses or employment. I have either read this application and all of the information contained in it, or have had it read to me. I have received a copy of the Customer Rights and Resp onsibilities and I agree to meet all obligations imposed upon me by submitting and signing this application. I solemnly affirm under the penalties of perjury that the statements given are true and correct to the best of my knowledge , information, and beli ef. Applicant’s Signature _______________________________________ Date ________________ DO NOT WRITE BELOW THIS LINE SECTION VII: SERVICES REQUIRED All establi shment/enforcement services Collection/en forcement Location of other parent Modification Establishment of paternity Establishment of court order Establishment/enforcement of health insura nce only SECTION VIII : VALIDATION $15 application fee paid Medical Assistance client. Fee does not apply. Fee previously paid TCA applicant -fee deferred. No fee paid. Explanation ____________________________ _____________________________ ____________________ Validator’s Signat ure (CS A Staff) Date DHS/CSA 980/980A (Revised 0 7/17) 7 Customer Rights and Responsibilities As a Customer of the Child Support Administration ( CSA) you have the following rights and responsibilities:  The right to available services regardless of your race, color, creed, national origin, or as defined by ADA.  The right to information regarding client rights including a copy of this document and/o r an explanation of client rights in a language of your choice, to the extent possible, and access to an interpreter in order to understand exercise and protect your rights.  The right to have your case record kept private as required by State and Federal laws.  The right to make suggestions or complaints when you think your services have been delayed or you disagree with a decision.  The right to get appropriate services that follow State, Federal, and local laws and regulations.  The right to be treated with respect and courtesy.  The right to be informed about any fee required in order to receive services. As a Customer of this agency you have a responsibility to:  Treat staff with respect and courtesy,  Give correct and complete information about persons in volved in your case,  Inform CS A immediately about changes in legal custody, your address, employment, income and health insurance,  Provide copies of all relevant court orders,  Attend all scheduled appointments,  Respond truthfully and timely to letters, notices or other inquiries from the Agency, and  Notify your local Child Support office before filing any civil or criminal action concerning child support. DHS/CSA 980/980A (Revised 0 7/17) 8 ATTACHMENT – FINANCIAL STATEMENT I, _________________________________________________________ , state that I am the mother/ father Name or __________________________________________ of the minor children listed below: State Relationship (aunt, guardian, grandmother, etc.) ___________________________________ _________ ____________________________________________ Name Date of Birth Name Date of Birth _______________________________________ ____________________________________________ Name Date of Birth Name Date of Birth ___________________________________________ ____________________________________________ Name Date of Birth Name Date of Birth The following is a list of my income and expenses .* See definitions before completing. Total monthly income (before taxes) $___________________ Child support I am paying for my other child(ren) each month $___________________ Alimony I am paying each month to _____________________ $___________________ Name of Person Alimony I am receiving each month from _____________________ $___________________ Name of Person For the children listed above: Monthly health insurance premium $___________________ Work -related monthly childcare expenses $___________________ Extraordi nary monthly medical expenses $___________________ School/transportation expenses $___________________ *To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3, and yearly expenses should be divided by 12. If you do not pay the same amount each month for any of the categories listed, determine your average monthly expense. Total Monthly Income: Include income from all sources including self -employment, rent, royalties, business income, salaries, wages, commission s, bonuses, dividends, pensions, interest, trusts, annuities, social security benefits, workers compensation, unemployment benefits, disability benefits, alimony or maintenance received, tips, income from side jobs, severance pay, capital gains, gifts, pri zes, lottery winnings, etc. do not report benefits from means -tested public assistance programs such as food stamps or TCA. Extraordinary Medical Expenses: Uninsured expenses over $100 for a single illness or condition including orthodontia, dental trea tment, asthma treatment, physical therapy, treatment for any chronic health problems, and professional counseling or psychiatric therapy for diagnosed mental disorders. Child Care Expenses: Actual child care expenses incurred on behalf of a child due to e mployment or job search of either parent with amount to be determined by actual experience or the level required to provide quality care from a licensed source. School and Transportation Expenses: Any expenses for attending a special or private elementary or secondary school to meet the particular needs of the child or expenses for transportation of the child between the homes of the parents. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information and belief. _____________________________________________ ____________ Signature Date