TDS-31008 | Rev. 11/19
Addendum to Application for Child Support Services | TCSP Case #: .
Child’s Health Insurance Coverage (Please attach copy)
Legal Name of Child: (Last, First, MI) Social Security Number:
Date of Birth: If Native American, what tribe?
Tribal ID#: Gender:
If the child is 18 years of age or older, and no longer enrolled in high school (e.g. the child graduated), please
provide a brief explanation of why you are choosing to pursue child support services.
Does the child live with you? Is he/she currently enrolled in school? Name of school:
Must provide verification of enrollment.
Yes No Yes No
Paternity established? If yes, how was it established? Date established?
Yes No
No Child Support Order has been established
Order of Support has been established
Date established:
If paternity of this child is in question, who is/are the alleged father(s)? Provide first and last names of individuals:
Who is the provider of health insurance? Father Mother Other
Public Private Effective Date:
Is the child enrolled in a health insurance plan? Name of Insurance Plan:
Yes No
Cost per month to cover only the child(ren) $
Child(ren) eligible for Indian Health Services (IHS)?
Yes No If yes, where?
P: 360-716-4556 F: 360-716-0309
2828 Mission Hill Rd, Tulalip, WA 98271
For Mailing: 8825 34th Ave NE, Suite L-545, Tulalip, WA 98271
Additional Child Information Form