TDS-31008 | Rev. 11/19
Addendum to Application for Child Support Services | TCSP Case #: .
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Child’s Health Insurance Coverage (Please attach copy)
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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
Type:
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
