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Application for Services (Columbia Gorge Community College)

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Page 1 of 5 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 10/01/19)
Oregon Child
Support Program
Application for Services
FOR OFFICE USE ONLY
Date application requested:
_____________________
Date application mailed to
requestor: __________
To apply for services from the Oregon Child Support Program, complete, sign, and date this application, or apply
online at OregonChildSupport.gov. Within two days after we receive it, we will review your application to
determine if you qualify for services. If you do, we will set up your case in our computer system. We will contact
you if more information is needed.
The attachment provides important information about the Oregon Child Support Program.
If you do not apply online, you can take this application to your local child support office or mail it to: Oregon
Child Support Program, PO Box 14680, Salem OR 97309. If you have questions, contact us at 800-850-0228.
Applicant’s Name
Please print:
General Information Complete these sections
Are you applying for all child support services? Yes No 1, 5, 6, 7, 8, 9
Are you applying for paternity establishment services with no child support order?
Yes No 2, 5, 6, 9
Are you applying for support services as a Child Attending School?
Yes No 3, 5, 8, 9
Are you applying for limited spousal support services only?
Yes No 4, 5, 9
Have you been making or receiving payments through an escrow agent?
Yes No
If yes, by your signature on this application, you authorize the escrow company listed below to release copies of support
payment information to the Oregon Child Support Program.
Name of escrow company Address Phone #
1. Child Support Orders
Has
parentage been legally established for all children?
Yes No
Is there a pending legal action in any state for child support?
Yes No
If yes, Court Case # County State
Is there an existing support order? Yes No
If yes, Court Case # County State
Do you want the existing order reviewed for a possible modification? Yes No
Are there arrears owed under the existing support order?
Yes No
If there are arrears, do you want collection of these arrears?
Yes No
Have you ever had a child support case with another state?
Yes No
If yes, which state?
Are there any other support, custody, divorce, or juvenile court orders about your children
or about you and the other parent?
Yes No
If yes, Court Case # County State
2. Paternity Establishment for Children Born in Oregon – No Child Support Order
Note: Services are available to establish paternity when a child does not already have two legally established parents.
If your child does not have two legally established parents and you want to establish paternity of
the father, are you and the other parent willing to sign a legal paper known as a Voluntary
Acknowledgment of Paternity to have the father’s name added to the birth record?
I
f a Voluntary Acknowledgment of Paternity cannot be completed, do you want the Oregon Child
Support Program to initiate a legal action to establish paternity?
If you decide during this action that you want a child support order and enforcement services,
you must notify
the office handling your case to request establishment and enforcement services.
Yes No
Yes No
Print
Save As
Reset
Page 2 of 5 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 10/01/19)
3. Child Attending School
Is there a pending legal action in any state for child support? Yes No
If yes, Court Case # County State
Is there an existing support order? Yes No
If yes, Court Case # County State
Do you want the existing order reviewed for a possible modification? Yes No
Are you married, on active military duty, or legally emancipated by a court order?
Yes No
Have you ever received cash public assistance in any state? Yes No
4. Spousal Support Orders
If you receive any form of public assistance, the Division of Child Support will provide income withholding and accounting
services. They will not provide any other services. Local district attorney offices may be able to provide limited services for
spousal support orders. Check with your local office.
By your signature on this application, you authorize the Department of Human Services to release your records to
the Oregon Child Support Program.
Is there a pending legal action in any state for spousal support?
Yes No
If yes, Court Case # County State
In what county is the existing spousal support order filed?
Court Case # County State
Are arrears (past-due support) owed under the spousal support order? Yes No
If arrears are owed, do you want collection of these arrears?
Yes No
Are there any other divorce or court orders about your spousal support?
Yes No
If yes, Court Case # County State
Are you receiving any state assistance at this time? Yes No
If yes, what type of assistance are you receiving?
All applicants must complete Section 5
5. Applicant Information
Full Name
Address
Male Female Other
Custodial parent
Non-custodial parent
Caretaker or guardian
Child Attending School
Person receiving spousal support
We will use your address to send you documents in the future. It may also appear in legal papers given to the other party and in
court records. If you do not want your address to be given to the other party or appear in court records, please contact us.
Mobile number:
Text? Yes No
Email:
Social Security number:
Date of birth:
Employer Name and Address:
Other Party 1 Information (Parent or Caretaker)
Full Name
Address
Male Female Other
Custodial parent
Non-custodial parent
Caretaker or guardian
Mobile number:
Text? Yes No
Email:
Social Security number
Date of birth:
Employer name and address:
Page 3 of 5 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 10/01/19)
Other Party 2 Information (if any)
Full Name
Address
Male Female Other
Custodial parent
Non-custodial parent
Caretaker or guardian
Mobile number:
Text? Yes No
Email:
Social Security number:
Date of birth:
Employer name and address:
Preferred Language
If you do not speak or read English, what language do you speak?
What language do you read? Do you need an interpreter? Yes No
If any other party does not speak or read English, what language do they speak?
What language do they read? Do they need an interpreter? Yes No
English
Need another language? Contact us.
French
Avez-vous besoin d’une autre langue? Communiquez avec nous.
German
Sie benötigen eine andere Sprache? Kontaktieren Sie uns.
Russian
Предпочитаете другой язык? Свяжитесь с нами.
Somali
Ma u baahan tahay luqad kale? Na la soo xiriir.
Spanish
¿Necesita otro idioma? Contáctenos.
Vietnamese
Quý vị có cần dùng ngôn ngữ khác không? Hãy liên lạc với chúng tôi.
6. Children Information (use additional sheets if necessary) Place of birth
Full name
Gender
Birth date
County/State
Social Security #
Male Female
Other
/ /
Male Female
Other
/ /
Male
Female
Other
/ /
Male
Female
Other
/ /
7. Health Insurance
Is health insurance available for the children? Yes No
If yes: Who is the policy holder? Non-custodial parent Custodial parent Other
Insurance company
Policy number
Address
Phone number
8. Public Assistance
Has the custodial parent or the children ever received cash public assistance in any state? Yes No
If yes, who received the cash assistance?
What state? Dates
9. I certify that the above information is true and correct to the best of my knowledge and belief.
Date: Signature:
Page 4 of 5 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 10/01/19)
Information about the Oregon Child Support Program
The Oregon Child Support Program includes the district attorney office in 22 counties and local Oregon
Department of Justice Division of Child Support offices. See our website at OregonChildSupport.gov for office
locations.
Services we provide
The Oregon Child Support Program cannot act as a lawyer for any party. We do not provide services or make
decisions regarding parenting time and custody as these matters are decided in the court system. You should
talk to a lawyer if you have any legal questions about your case. Low cost legal services may be available. For
further information, you may visit our website at OregonChildSupport.gov.
Applicants will be provided all appropriate services. An applicant for services cannot choose or limit which
services will be provided. However, limited services are provided for spousal support enforcement and
establishment of paternity with no child support order. If circumstances change and full services are desired,
you must contact your local office to apply.
The program provides services to establish paternity, as well as to establish and modify child support orders.
We enforce orders to collect child support payments and obtain medical support. We will also enforce spousal
support included with a child support order.
Your rights and responsibilities
• The Oregon Child Support Program complies with applicable federal civil rights laws and does not
discriminate on the basis of race, color, national origin, disability, religion, sex, gender identity, sexual
orientation, or age.
• You are responsible for keeping us informed of your current address. If we cannot contact you, we may
close your case. Your case may also be closed if you do not provide necessary information, sign legal
documents, or cooperate when asked.
• We will protect your personal information by following all state and federals laws and court
requirements. If you do not want your address to be given to the other party or to appear in court
records, contact your local office.
• You are required to provide your Social Security number to the Oregon Child Support Program. This is
mandatory under federal law [42 USC §405(c)(2)(C) and 42 USC §666(a)(13)]. We will use your Social
Security number as one of the identifiers to find you and your records for purposes of establishing
paternity and establishing, modifying, and enforcing support obligations. You may be asked for your
case number or your Social Security number when you call us or when completing forms so we can
correctly identify your case.
• All parties have equal status in child support cases. Any party can ask questions, raise issues, or
request changes, with or without assistance from a lawyer.
• When providing child support services, we will serve parties with copies of notices and legal actions as
necessary. The papers will be served by regular mail, priority mail, certified mail, or in person. These
papers will let you know what is happening with your case. Accepting the papers does not mean you
agree with what is in them and does not take away your legal right to dispute any actions or decisions.
• When receiving child support services, you have the right to ask the Program to review your child
support order using the current guidelines to determine if the amount should be increased or lowered.
Information about establishing paternity
We will not pursue establishment of paternity if:
• Adoption of the child is final,
• Parentage has already been established for the child, or
• The director of the Oregon Child Support Program determines that establishing paternity is not in the
best interests of the child.
If either parent claims another person is the father, you may be required to submit to a parentage test to
provide evidence of paternity
Page 5 of 5 - APPLICATION FOR CHILD SUPPORT SERVICES
CSF 03 0574 (Rev. 10/01/19)
If you apply to establish paternity without a child support order, any information provided to us can be used in
any future action to establish a support order.
How we disburse child support payments
When a parent or child attending school is receiving services from the Oregon Child Support Program, all child
support payments must go through us. Payments are received by the program’s accounting team, which
records the payments and then sends the money to the party who is owed the support.
If the children are not in the custody of the state, we send the money electronically to the person owed support.
The Program keeps the money for the children in the state’s custody. If the children are receiving Temporary
Assistance to Needy Families (TANF), the Program may send some of the money to the family and keep the
rest of the payment. This is called a pass-through. If there are qualified children attending school, they will
receive their portion of the payment and the parent or caretaker will receive the remaining payment. General
information about how we disburse money is found in Oregon Administrative Rule (OAR) 137-055-6021. More
information about the pass-through is in OAR 137-055-6010.
Fees for services
A one-time fee of $1 for processing your application will be deducted from the first collection. The Oregon Child
Support Program also charges fees for other services.
If past-due support on your case is collected by intercepting the paying parent’s federal or state tax refunds, a
collection fee will be deducted from the amount distributed to the person receiving support. The IRS charges
$19.64 per collection from federal tax refunds. The Oregon Department of Revenue charges 3.5 percent of the
amount collected from state tax refunds.
Annual fee
Federal law requires an annual fee on child support cases involving families receiving support who have never
received TANF cash benefits. The annual fee is withheld from child support payments after the family receives
a certain amount during the federal fiscal year. The federal fiscal year runs from October 1 to September 30.
The annual fee is $35 after the family receives $550. No annual fee is charged if less than $550 is collected.
Grievance process
Our goal is to give you fair, professional, courteous, and accurate service. If you believe you did not receive
high-quality service from one of our offices, contact a supervisor at that office. If you are unable to resolve the
issue with the supervisor, you may contact Constituent Services at 503-947-4388. You can also submit a
grievance form explaining your complaint at any time. The form is available at any Oregon Child Support
Program office and on our website at OregonChildSupport.gov.
If your complaint is about a decision or action required by federal or state law, we may not be able to resolve
your issue. We will explain the reason for our decision.
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Completed 21 July 2020

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