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CHILD SUPPORT SERVICES APPLICATION SAINT REGIS MOHAWK TRIBE (St Regis Mohawk Tribe)

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CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 1 | 6
SAINT REGIS MOHAWK TRIBE
CHILD SUPPORT ENFORCEMENT UNIT
CHILD SUPPORT SERVICES APPLICATION
Filling out this application form:
Please fill out the form to the best of your knowledge.
Please print or type all answers.
The children for which you are requesting services should have the same mother and father. If any
of the children have a different mother or a different father, please fill out a separate form for each
child(ren).
Custodial Parent is defined in the SRMT FSA as “the person who has primary physical placement
of the child, whether by voluntary agreement or by Court Order”.
Non-Custodial Parent is defined in the SRMT FSA as “the parent with whom the child (ren) do not
live with a majority of the time”.
TANF is Temporary Assistance for Needy Families, previously known as welfare.
The more information you provide, will enable us to serve you better.
You will be required to provide proof of certain information. The needed proof of information is listed
on the Verification Checklist below. If you are unable to provide some of the requested information,
please schedule an appointment.
If you have any questions or need assistance filling out this application, please ask for our help. Our
staff is available to assist you in completing the application form
Application Checklist: We will need the following verification and documentation in order to process
your application for Child Support Services.
o Verification of Social Security Numbers for applicant and child(ren)
o Copy of the Birth Certificate for the child(ren)
o Verification of your address (rent receipt, utility bill)
o Verification of Tribal Enrollment/Valid Tribal ID
o Copies of any Court Orders (Child Support, Divorce or Custody)
o If family violence is alleged, please provide a copy a valid Order of Protection or Domestic Incident
Report and complete a request form for Non-Disclosure
o Copies of any receipt or proof of child support that has already been paid to you
o A signed Legal Representation Information Form
CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 2 | 6
Understanding:
The Saint Regis Mohawk Tribe Child Support Enforcement Unit (SRMT CSEU) does not
represent either party in the case. We are here to serve the best interests of the child(ren).
The information that you provide on this form will be confidential. The SRMT CSEU will
not release any of your confidential information without your written consent, unless it
permitted to do so by law.
Once you have completed this form, signed it and returned it to our office, we will review
the information that you have provided. If we have any questions, we will contact you for
more information.
You must notify us immediately of any changes in your address, employment status or any
other information you provide. You must also update us about any changes to the non-
custodial parent’s address, employment status or any other information you have.
Return your completed Application to:
Saint Regis Mohawk Tribe
Child Support Enforcement Unit
412 State Route 37
Akwesasne, NY 13655
518-358-2272 Ext. 2410
****************************************************************************************************************
(PLEASE KEEP THIS FOR YOUR RECORDS, THE CSEU WILL ONLY KEEP THE REMAINING
3 PAGES OF THE APPLICATION)
CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 3 | 6
SERVICES REQUESTED
o Establishment of Paternity
o Establishment of a Child Support Order
o Location Services
o Registration of Foreign Order
APPLICANT /CUSTODIAN INFORMATION
Name: SS#:
DOB: Tribal Enrollment #: Tribe:
Phone: Cell: Work:
State/Province Driver’s License #
Mailing Address:
Physical Address:
Are your currently or ever received TANF: Y N Where:
Are you or have you been a victim of Family Violence: Y N
If yes, do you currently have a restraining order or order of protection? Y N
NON-CUSTODIAL PARENT (NCP) INFORMATION
Father’s Name: SS#:
DOB: Tribal Enrollment#: Tribe:
Phone: Cell: Work:
State/Province DL#
Mailing Address:
Physical Address:
Height: Weight: Hair Color: Eye Color:
Distinguishing marks (tattoos, scars, etc.):
Family members who may assist with location:
CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 4 | 6
Mother’s Name: SS#:
DOB: Tribal Enrollment#: _Tribe:
Phone: Cell: Work:
Mailing Address:
Physical Address:
Height: Weight: Hair Color: Eye Color:
Distinguishing marks (tattoos, scars etc.):
Family members who may assist with location:
CHILDREN INFORMATION
NAME
SEX
SSN
Tribe/Enrollment
Number
Paternity
Established?
CUSTODIAL PARENT (CP) FINANCIAL INFORMATION
Is the CP currently working? Y N
Employer Name/Address:
Employer Phone: Hours per Week: Hourly Pay:
Is Health Insurance available through employer? Y N
List other sources of income:
Source: Amount: Frequency:
Source: Amount: Frequency:
Source: Amount: Frequency:
School/Training:
Vehicle:
Bank Account:
Degree/Certificate:
Approx. Value:
Bank:
Other financial assets:
CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 5 | 6
NON-CUSTODIAL PARENT (NCP) FINANCIAL INFORMATION
Is the NCP currently working? Y N
Employer Name/Address:
Employer Phone: Hours per Week: Hourly Pay:
Is Health Insurance available through employer? Y N
List other sources of income:
Source: Amount: Frequency:
Source: Amount: Frequency:
Source: Amount: Frequency:
School/Training:
Vehicle:
Bank Account:
Degree/Certificate:
Approx. Value:
Bank:
Other financial assets:
MARRIAGE AND PATERNITY INFORMATION
Were the parents of the child ever married to each other? Y N
If yes date of marriage: Place of marriage:
If never married to each other was there an Acknowledgement of Paternity signed? Y (provide copy) N
If never married to each other, has paternity for the child (ren) already been established by either a State or
Tribal Court? Y (provide copy) N
COURT ORDER INFORMATION
If the parents were married, are they now divorced? Y N
Date of Divorce: Place of Divorce:
Is there an order that requires the NCP to pay child support for any child? Y (provide copy) N
What Court: Type of Order: Date Ordered:
Have you ever applied for Child Support Services for any of these children in the past? Y N
Agency where applied: Date:
CHILD SUPPORT SERVICES APPLICATION
APPLICATIONAPPLICATION
SRMT CSEU CASE#
DATE SUBMITED:
P a g e 6 | 6
MY UNDERSTANDING
I understand that all the information that I give is, to the best of my knowledge, true and correct and that
it may be used in Court.
I agree to tell the SRMT CSEU of any new or changed information that relates to the information that
I have already provided.
I authorize the SRMT CSEU to collect child support on my behalf.
PRINT NAME RELATIONSHIP TO CHILD (REN)
SIGNATURE DATE
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CHILD SUPPORT SERVICES APPLICATION SAINT REGIS MOHAWK TRIBE (St Regis Mohawk Tribe)

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Completed 20 July 2020

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