Fillable Application for Child Support Services (The Tulalip Tribes)

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Application for Child Support Services (The Tulalip Tribes)

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The Application for Child Support Services (The Tulalip Tribes) form is 9 pages long and contains:

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  • 11 check-boxes
  • 242 other fields

Country of origin: US
File type: PDF

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1
Application for Child Support Services
TDS-31008 | Rev. 11/19
Custodial Parent: This section is about the person who has custody of the child(ren).
w
Legal Name: (Last, First, MI) Alias or Maiden Name:
Date of Birth: Place of Birth: (City, State or Country) Social Security Number: Gender: M F
_ Other
Race: If Native American, which tribe? Tribal ID#:
What is the relationship of the children to the custodial parent?
Mailing Address: (City, State, ZIP Code)
Home Address: (If different from mailing)
Phone: Alternate Contact:
Employer Name: Employer Phone Number:
Employer Address: (County, City, State, ZIP Code)
Income:
$ Hourly OR $ Monthly OR $ Annually
Is the family receiving TANF?
Yes No
If yes, State or Tribal TANF?
State Tribal
Is the family receiving Medicaid?
Yes No
Is the family receiving medical coupons?
Yes No
How long since you have received any service?
Is a private attorney currently working on your child support case?
Yes No If yes, attorney’s phone number:
Do you have a Child Support order? Yes No
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
2
TDS-31008 | Rev. 11/19
Non-Custodial Parent: This section is about the person who does not have custody of the child(ren).
w
Legal Name: (Last, First, MI) Alias or Maiden Name:
Date of Birth: Place of Birth: (City, State or Country) Social Security Number: Gender: M F
_ Other
Race: If Native American, which tribe? Tribal ID#:
Height: Eye Color: Hair Color:
Identifying Marks:
Mailing Address: (City, State, ZIP Code)
Phone: Alternate Phone:
Email:
Is non-custodial parent currently remarried?
Yes No
Total number of children non-custodial
parent is responsible for?
Employer Name: Employer Phone Number:
Employer Address: (County, City, State, ZIP Code)
Income:
$ Hourly OR $ Monthly OR $ Annually
Does non-custodial have an occupational license? If yes, what kind? (Drivers License, Tribal Gaming, CDL)
Does the non-custodial belong to a union?
Which one?
Does the non-custodial have a second job?
If so, where?
Has the non-custodial ever been
in jail?
If yes/presently, for how long?
Release date:
Where? County/City/State
Is the non-custodial retired? Yes No
From what kind of work?
Is non-custodial on disability? Yes No
If yes, what type of disability?
Does the non-custodial receive or pay child support payments on any other case? Yes No
If yes, for how many children? Amount $
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
2
TDS-31008 | Rev. 11/19
Non-Custodial Parent 2: This section is about the person who does not have custody of the child(ren).
w
Legal Name: (Last, First, MI) Alias or Maiden Name:
Date of Birth: Place of Birth: (City, State or Country) Social Security Number: Gender: M F
_ Other
Race: If Native American, which tribe? Tribal ID#:
Height: Eye Color: Hair Color:
Identifying Marks:
Mailing Address: (City, State, ZIP Code)
Phone: Alternate Phone:
Email:
Is non-custodial parent currently remarried?
Yes No
Total number of children non-custodial
parent is responsible for?
Employer Name: Employer Phone Number:
Employer Address: (County, City, State, ZIP Code)
Income:
$ Hourly OR $ Monthly OR $ Annually
Does non-custodial have an occupational license? If yes, what kind? (Drivers License, Tribal Gaming, CDL)
Does the non-custodial belong to a union?
Which one?
Does the non-custodial have a second job?
If so, where?
Has the non-custodial ever been
in jail?
If yes/presently, for how long?
Release date:
Where? County/City/State
Is the non-custodial retired? Yes No
From what kind of work?
Is non-custodial on disability? Yes No
If yes, what type of disability?
Does the non-custodial receive or pay child support payments on any other case? Yes No
If yes, for how many children? Amount $
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
3
TDS-31008 | Rev. 11/19
Please list only children having the same mother and father on this one application. If there are more than
two children, fill out a separate “Additional Child Information Form” for other child.
w
Legal Name of Child: (Last, First, MI) Social Security Number:
Date of Birth: If Native American, what tribe?
Tribal ID#: Gender:
Legal Name of Child:
(Last, First, MI) Social Security Number:
Date of Birth: If Native American, what tribe?
Tribal ID#: Gender:
Does the child(ren live with you? Are they 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 the child is in question, who is/are the alleged father(s)? Provide first and last names of individuals:
Child’s Health Insurance Coverage (Please attach a copy of insurance)
Is the child(ren) enrolled in a health insurance plan? Name and Identifying number of insurance plan:
Yes No
Who is the provider of health insurance?
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
Child 1 and 2 Information Form
4
TDS-31008 | Rev. 11/19
Please list only children having the same mother and father on this one application. If there are more than
two children, fill out a separate “Additional Child Information Form” for other child.
w
Legal Name of Child: (Last, First, MI) Social Security Number:
Date of Birth: If Native American, what tribe?
Tribal ID#: Gender:
Legal Name of Child:
(Last, First, MI) Social Security Number:
Date of Birth: If Native American, what tribe?
Tribal ID#: Gender:
Does the child(ren live with you? Are they 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 the child is in question, who is/are the alleged father(s)? Provide first and last names of individuals:
Child’s Health Insurance Coverage (Please attach a copy of insurance)
Is the child(ren) enrolled in a health insurance plan? Name and Identifying number of insurance plan:
Yes No
Who is the provider of health insurance?
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
Child 3 and 4 Information Form
5
TDS-31008 | Rev. 11/19
Parents’ Marital Relationship
Miscellaneous Information:
Parents’ Marital Relationship
What was the relationship between the mother and father of the child(ren) listed?
Never Married Married, Living Apart Divorced, When:
Date of Marriage: Date of Separation:
City, County, State
What was the relationship between the mother and father of the child(ren) listed?
Never Married Married, Living Apart Divorced, When:
Date of Marriage: Date of Separation:
City, County, State
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
6
Domestic Violence Information
Request for Case Transfer from Another Agency to TCSP
TDS-31008 | Rev. 11/19
Referral: Were you referred to TCSP from another agency or department? Yes No
If yes, please provide the name of referring agency/department:
Comments: Please provide any additional information that you feel could assist our office in enforcing
your child support order:
Do you believe that you or your child(ren) may be at risk of emotional or physical harm if the other parent
knows where to find you?
Yes No Why?
Have you ever had a protective order against you or the Non-Custodial Parent? If yes, which court issued the
order? Still in effect? (if so, please attach a copy)
Yes No Date Issued:
Have you or your child(ren) experienced any type of abuse? Yes No
Type of abuse: Physical Verbal Sexual Mental
If yes, do you want to complete a Domestic Violence Risk Assessment form? Yes No Later
Return completed form to the TCSP office. If you decide to NOT fill out a form a this time, you may request
one later.
I am requesting that my case(s), listed below, be transferred from the listed agency(s) to the Tulalip Child
Support Program. I understand that by making this request that all future actions on my cases will stop with
above named agency and a new case(s) will be initiated with the TCSP. I also understand that this document is
my official request for the TCSP to manage all future child support activities related to my case(s) beginning on:
Date:
Case #1: with
(Case number or social security number) (Name of agency case originated)
Case #2: with
(Case number or social security number) (Name of agency case originated)
Case #3: with
(Case number or social security number) (Name of agency case originated)
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
Referral and Comments
7
Statement of Understanding
TDS-31008 | Rev. 11/19
1. I understand that the TCSP is here to act in the public interest to protect the rights of children, the Tulalip
Tribes, and to make sure that both parents financially support their children. Information I provide will
not be divulged to general public, but may be used as needed to collect support from either parent.
I give TCSP permission to provide any necessary information to law enforcement officers, public officials,
courts, and others as is required to assist in the collection of child and/or medical support.
2. I understand that the TCSP attorney cannot act as my legal representative. The attorney has an
attorney-client relationship only with the Tulalip Tribes and the TCSP. The attorney does not have
an attorney-client relationship with me, or with any recipient of child support services.
3. Any communication between the TCSP attorney and a mother, father, alleged father(s), child, or any
other party in a paternity or child support action, shall not be considered privileged or confidential, except
as otherwise required by a specific tribal or federal law. The TCSP attorney may speak with me and
explain the services available to me through the child support program, and explain the nature of legal
proceedings and legal documents. The attorney may ask me questions regarding a case. However, the
TCSP attorney does not represent me. What I say will not remain a secret between me and the attorney,
because the attorney will share the information with TCSP and its staff members. That information will
be considered by TCSP in making its case decisions, and may be used in presenting information to the
court. The TCSP attorney may ask the court to enter orders that will favor me. But this does not mean
that the attorney represents me. Or the attorney may ask the court to enter an order that is not in my
favor. I understand that I have the right to have my own attorney represent me, at my own expense, in
any legal proceeding before the Tulalip Tribal Court.
4. I understand if I accept child support payments that I am not entitled because the non-custodial parent
paid me directly for support assigned to the tribe or state, or because payments were sent to me in
error, TCSP will recover the overpayment from me. Furthermore, TCSP may recover any such
overpayment by withholding amounts from my child support payments. I understand it is required
that TCSP collect money owed to the tribe or state for any TANF my children received in the past or
are currently receiving.
5. I agree to cooperate fully with TCSP, law enforcement officers, and the court. I will notify TCSP of
any change(s) of circumstance (including address and contact info).
6. By signing this statement, I am verifying that the information provided in this application is true and
correct to the best of my knowledge. My signature also confirms that I agree to the service terms
specified above. I am giving consent to the TCSP to handle my case.
Date: X
(Signature and Printed Name of Requesting Party)
Date: X
(Signature and Printed Name TCSP Employee’s)
Please complete this form and return to the TCSP office via fax at 360-716-0309, or by mail/drop-off
to 8825 34 Ave NE St L-545, Tulalip, WA 98271 . Do not hesitate to contact a Tulalip Child Support staff
member at 360-716-4556 if you have any questions about this form or need additional forms.
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
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8
Authority For Release Of Confidential Information
TDS-31008 | Rev. 11/19
My Name: Last First MI Date of Birth:
TCSP Program Case #: Social Security Number (Last 4): Tribal ID #:
XXX-XX-
I understand that my personal and financial records are protected under federal and state confidentiality regulations
and cannot be disclosed to anyone without my written consent — unless it is directly related to child support services
(establishment of paternity; establishment, modification, and enforcement of child support obligation; and locating
parents and their financial assets).
By checking this box I hereby authorize the Tulalip Child Support Program (TCSP), (employee’s) to disclose and receive
protected personal and fmancial information about me to such/from such tribal or governmental agencies including
the Tulalip Tribal Court, Tulalip Finance, Membership Distribution, Natural Resources, Higher Education Tulalip
Housing, Central Benefits, Betty J. Taylor Early Learning Center,
bədaʔchəlhbədaʔchəlh and Youth Services. As is necessary to
carry out TCSP’s official duties. This information may be provided verbally, or by computer data transfer, mail, fax, or
hand delivery.
This release is valid for two years from the date signed below. A copy of this form shall be considered as valid as the
original. I further understand that I may revoke this consent at any time, except to the extent that action has already been
taken in reliance on this consent.
If this box is checked, and names are provided below, I also direct send authorize TCSP to release such
confidential information pertaining to my case to the following:
(Last, First name of recipient you are wanting TCSP to release information to*) (Relation to Me)
(Designate Party Address) (City, State, ZIP Code)
(Contact Number and Email Address)
Date My Signature
Date Signature of TCSP Representative
SUBSCRIBED AND SWORN before me on this: day of 20
X
NOTARY PUBLIC in and for the State of Washington
County of Snohomish
X
Printed Name
My Commission Expires:
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
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signature
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10
Helpful Information
TDS-31008 | Rev. 11/19
For more information, email tcse@tulaliptribes-nsn.gov
Tulalip Child Support Staff:
Roseann Reeves Manager 360-716-4525 rreeves@tulaliptribes-nsn.gov
Lynne Bansemer Supervisor 360-716-4567 lybansemer@tulaliptribes-nsn.gov
Kaylee Grant Enforcement
Officer
360-716-4524 kayleegrant@tulaliptribes-nsn.gov
Denise Krout Enforcement
Officer
360-716-4521 dkrout@tulaliptribes-nsn.gov
Dustin Henry Enforcement
Officer
360-716-4528 dustinhenry@tulaliptribes-nsn.gov
Marlee Paul Enforcement
Officer
360-716-4523 marleepaul@tulaliptribes-nsn.gov
TBD Intake
Specialist
360-716-4559 tcse@tulaliptribes-nsn.gov
Nicole Ferguson Finance
Specialist
360-716-4557 nferguson@tulaliptribes-nsn.gov
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
Tax Records
You can retrieve tax records from the IRS website:
www.irs.gov
• Go under “TOOLS”
• Click, “Get Transcript of Your Tax Records”
Follow each prompt to create your account and view
your personal records. Please note that you will need
to submit your information as it shows EXACTLY on
your tax returns.
Birth Certificates:
Vital Statistics
3020 Rucker Ave, Suite 104
Everett, WA 98201
425-339-5280
Cost: $20.00 each
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Application for Child Support Services (The Tulalip Tribes)

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Completed 27 January 2021

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