Fillable Child Support Services APPLICATION FOR SERVICES Thank you (Henderson County)

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Child Support Services APPLICATION FOR SERVICES Thank you (Henderson County)

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DSS-4451 (rev. 06/17)
ACTS/CSS Application WWW.NCCHILDSUPPORT.COM
Child Support Services
APPLICATION FOR SERVICES
Thank you for your interest in the North Carolina Child Support Services (NCCSS) program. Child support services are
available to all applicants: parent, alleged fathers, non-parent caretakers, minor children, social services agencies and
judicial officials. If you decide to apply for child support services, please complete the application in its entirety and sign
where appropriate.
To help us process your application as quickly as possible, please return the following:
• The application (filled out completely, to the best of your ability)
• Proof of your income, if you are the child(ren)’s parent (e.g. pay stubs, tax returns, etc.)
• Copy of your Photo ID (e.g. driver’s license)
• Copy of each child’s state-issued birth certificate and Social Security card
• Photo of the child’s other parent (noncustodial parent from whom child support services are being requested)
• Copy of marriage certificates; if not available, provide dates of marriage and/or other verification of marital
status of the children’s parents
• Copy of any legal documents related to the child(ren) included in this application, such as:
o Affidavit of Parentage - a legal document signed voluntarily by both parents (either in the
hospital or at any time after the birth of the child) that establishes paternity
o Paternity order (court order establishing paternity)
o Child support and/or spousal support order(s) (all initial and modified orders)
o Agreement signed voluntarily by the parents for child support
o Copy of the child(ren)’s parent’s marriage and/or divorce decree
o Order(s) terminating parental rights
o Domestic violence protective order(s)
• Payment records of all support paid directly to the custodial parent or through a court
Mail or take your completed application and applicable documents, along with your non-refundable $25 application fee,
to the child support agency. The application fee must be a certified check or money order made payable to the specific
county that you are requesting to handle your support case (e.g. “Wake County Child Support Services”). Some local
child support agencies may also accept cash payment when applying in person. If your income is below 100 percent of
the Federal Poverty Guidelines, you may qualify for a reduced non-refundable $10 application fee. Please contact the
child support agency if you need assistance determining if you qualify for a reduced application fee.
If you need additional information or assistance in completing the form, you may contact the local child support agency
or call the NCCSS Customer Service Center at 1-800-992-9457.
Respectfully,
Child Support Representative
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To start the child support services process, please complete the following steps:
Step 1:
• Read the North Carolina Child Support Services (NCCSS) services, policies, applicant rights and responsibilities,
and Sign and Date (p. 3-5)
Step 2:
• Complete Section 1 – Applicant/Public Assistance Recipient Information
o You MUST select the appropriate information boxes, and Sign and Date
o If you are a minor child applicant requesting child support services from your own parents, fill out
Section 1 and all other sections except Section 3
Step 3:
• Complete Section 2 – Custodial Parent/Guardian Information
Provide the caretaker of the child(ren)’s information
o If you are the noncustodial parent applying for service, provide the caretaker of the child(ren)’s
information
o ONLY complete the income section if your relationship is “mother” “father” “alleged father” or “self”
to the child(ren) for whom you are requesting services
Step 4:
• Complete Section 3 – Minor Child Information
Complete for each child for whom child support services are being requested
o If you are applying for child support services for more than two children, please complete an additional
Section 3 for each additional child and attach it to the application. You can get additional copies of
Section 3 from the child support website (www.ncchildsupport.com), or by calling the NCCSS Customer
Service Center at (800) 992–9457 or your local child support agency
o Minor child applicants may skip this section and go to Section 4
Step 5:
• Complete Section 4 – Noncustodial Parent Information
o Provide information about the noncustodial parent(s) from whom child support services are being
requested. If the application is for more than two noncustodial parents, please complete an additional
Section 4 for each additional noncustodial parent and attach it to the application. You can get additional
copies of Section 4 from the child support website (www.ncchildsupport.com), or by calling the NCCSS
Customer Service Center at (800) 992–9457 or your local child support agency
Step 6:
• Complete Section 5 – Attachments
Check each item that you are attaching to the completed application
o If an item being attached is not one of the options, please check the option “Other” and write the item
description
Step 7:
• Complete Section 6 – Other Information
List any information that has not been provided in the application that may assist the child support agency in
processing your application
Step 8:
• Complete Section 7 – Certificat
ion Statement
o You MUST Sign and Date
Step 9:
• Detach and keep the “APPLICANT COPY” for your records (p. 23-24)
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North Carolina
Department of Health & Human Services
FOR AGENCY USE
Date Application Requested: ________________
Date Application Mailed: ________________
Date Application Received: _______________
__
Services: Child Support ___ Medical Support____
Locate Only ____
IV-D # ___________________
NPA ____ TANF______ MAO______ FC_______
Fee paid by: CP __ NCP _____
Amt. $ ________ Cash ___ Money Order ____
_
Certified Check____
Division of Social Services
Child Support Services
1-800-992-9457 Toll Free
APPLIC
ATION FOR SERVICES
North Carolina Child Support Services (NCCSS) administers the North Carolina child support program under Title IV-D of
the Social Security Act. Services are available to a parent, alleged fathers, non-parent caretakers, minor children, social
services agencies and judicial officials. The child support program’s goal is to provide the best possible services to families
for children. Whether you are making an application for child support services as a recipient of assistance from other
social services programs (Temporary Assistance to Needy Families [TANF], Foster Care and/or Medicaid) or requesting
child support services as a non-public assistance applicant, your involvement, information, and contributions are
important and required.
NORTH CAROLINA CHILD SUPPORT SERVICES INFORMATION
PROGRAM SERVICES
NCCSS provide child support services to assist families in meeting their financial obligations for children. There is no
residency or citizenship eligibility requirement for services. Depending on the circumstances of each family, one or more
of the following services may be appropriate:
• Location of noncustodial parent – State, federal, local and national resources are used to assist in collecting
information about a parent, such as their residence, employment and/or financial assets.
• Paternity establishment – A determination of parental legal responsibility for the child(ren) is necessary before
a parent can be required to pay support. If a child’s parents were not married to each other at the time of the
child’s birth, arrangement of paternity testing may be offered to the parties, if appropriate.
• Support establishment – In North Carolina, support is determined using the guidelines established in state law.
N.C. Child Support Guidelines consider both parent’s monthly gross incomes, the amount of time the child spends
with each parent and various expenses. NCCSS seeks to establish a court order requiring a parent to provide
child and/or medical support for child(ren) based on the N.C. Child Support Guidelines.
• Collection of support – Child support payments through bank draft, money order, or check are sent to N.C. Child
Support Centralized Collection (NCCSCC). A large amount of child support payments is deducted from a parent’s
wages and sent to NCCSCC by an employer. North Carolina Child Support Services records and disburses all
collected child support payments to families by personal direct deposit into a bank account or debit card.
• Enforcement of support – Enforcement of an established or existing child support, spousal support, and/or
medical support court order is met by wage withholding, tax refund offset, liens, professional license/passport
revocation, credit reporting, court action or other collection remedies. Support orders may be reviewed for
modification (increase/decrease) every three years or more often, if warranted.
NCCSS does not provide the following services: custody, visitation or the establishment of spousal support obligations.
PROGRAM FEES
• Application Fee – Families receiving public assistance (TANF, Medicaid and/or Foster Care) are not charged an
application fee for support services. Families that are not receiving public assistance are charged a non-
refundable application fee of up to $25. If the applicant’s income is below 100 percent of the Federal Poverty
Guidelines, a reduced application fee of $10 is available. Contact your local child support agency for additional
information about qualifying for the reduced application fee. The application fee must be paid before support
services can begin.
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• Annual Services Fee – Each year, non-public assistance child support cases (cases that public assistance has never
been provided) are charged a non-refundable $25 fee after at least $500 in support payments has been paid to
the family. The annual service fee is automatically deducted from support payments made to the custodian, and
is collected during each federal fiscal year, from Oct. 1 through Sept. 30.
• Administrative Offset Fees – Department of Revenue or Internal Revenue Service (IRS) fees may be deducted
from the noncustodial parent’s tax refund(s) collected for past due support before being disbursed as a support
payment to the custodial parent. The noncustodial parent is credited with the full tax refund(s) amount collected.
• Legal Fees – Agency attorney services and court fees are paid by the agency, or may be charged to the
noncustodial parent as allowed by law. There is no cost to a custodial parent for legal fees when a court action
is established by the agency. However, any costs for private legal services obtained by either parent are the
parent’s responsibility.
PROGRAM DISTRIBUTION
• Distribution of Support – Support payments are disbursed in accordance with federal regulations. Support
payments are paid toward all the noncustodial parent’s current support obligations first, except for tax refund
offsets which are paid toward any state debt owed first. Support payments are deposited to an agency-issued
debit card or personal bank account. Support payments exceeding the noncustodial parent’s current support
obligations are applied to any past due support.
• Tax Refund Offset – Support payments received from a joint tax return offset may not be distributed for up to
six months. The IRS may adjust a refund amount, which may require the custodial parent to return some or all a
support payment received from a tax refund. Tax refund offsets are applied to eligible cases annually.
OTHER PROGRAM POLICIES & INFORMATION
• Disclosure of SSN – Social Security numbers are obtained and kept on file at the local child support agency to
locate and identify individual’s assets for the purposes of establishing, modifying and enforcing child support
obligations. Enrolling a child in health care coverage may require the release of the child’s Social Security number
and mailing address to the other parent’s employer, or the release of the child’s Social Security number to the
other parent.
• Confidentiality
– Child support case records are not public records. The information in your case may be
discussed with or given to other state child support services, and/or other public agencies that can legally receive
such information and to the other parent or his/her attorney to the extent required by law. If the local child
support agency is notified that family/domestic violence is an issue, the local child support agency must take
additional steps to further safeguard information.
• Nondiscrimination
– In accordance with the Civil Rights Act of 1964, NCCSS ensures that all individuals are treated
equally, and that no person is discriminated against in the selection or eligibility to receive services in any manner
prohibited by law.
• Intergovernmental Cases
– Federal law requires every state to enact the Uniform Interstate Family Support Act
(UIFSA) 2008 to aid states in working together to establish and enforce child support orders. Every state, and
many tribes, foreign countries, territories or tribunals have an agency to enforce child support orders. If parents
do not live in the same state, although laws differ, child support agencies work with each other to locate parents
and to establish and enforce orders.
• Case Management Decisions
– Local child support agencies determine the appropriate services for child support
cases, as well as the way services are delivered by the agency. Reasonable and necessary actions to best serve
your case will be considered; however, specific time frames or results cannot be guaranteed.
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APPLICANT RIGHTS & RESPONSIBILITIES
All applicants: either parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and
judicial officials in a child support case have the following rights and responsibilities:
Rights
• To make an application for child support services at a local child support agency
• To be provided information about the status of your child support case
• To establish an account on the eChild Support website (www.ncchildsupport.com) to access case
information
• To receive notice of all pending court actions and to be provided copies of all court orders from court
hearings related to your child support case
• To request that the support order be reviewed or modified at least every three years
• To request a review of case management or distribution of funds in your case
• To hire a private attorney (at your own cost) to represent your interests in the child support case. The child
support attorney represents the child support agency, and cannot represent you in child support or other
legal matters regarding the child, such as custody and visitation
Responsibilities
• To provide the child support agency information that may help in the progression of the child support case
• To attend any appointments and/or hearings for which you have been provided notice that your
participation is needed
• To notify the child support agency of changes in your address and/or employment
• To notify the child support agency if the child being provided services:
o Is no longer in your custody
o Graduates or ceases to attend high school
• To repay any payments received in error
Additional information about the Child Support program is available at www.ncchildsupport.com
I have read or have had explained to me the above information about the North Carolina Child Support Services program
policies, services and my rights and responsibilities. By signing below, I acknowledge that I have received a copy of the
above information.
Print Legal Name
Signature of Applicant Date
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SECTION 1 – APPLICANT/PUBLIC ASSISTANCE RECIPIENT INFORMATION
I,
First Middle Last
(select the appropriate box, must select one)
□ DO NOT RECEIVE:
Temporary Assistance for Needy Families (TANF), Work First,
Medicaid or Foster Care services from the Department of
Social Services for the child(ren) named below. I am applying
for services of the child support agency for the benefit of the
child(ren) listed below. I understand that this application
establishes a contract with North Car
olina Child Support
Services, and that services will begin once the local child
support agency receives the completed application and any
required application fee.
□ Temporary Assistance for Needy Families (TANF)
□ Work First □ Medicaid □ Foster Care assistance
for the child(ren) listed below. I understand that eligibility
for this assistance may require me to work with the child
support agency in pursuing support for the child(ren).
I agree to coop
present good cause and I am granted exemption from this
requirement by the Work First, Medicaid, or Foster Care
Write the full name of each child for whom child support services are being requested:
(If additional space is needed, provide the information on a separate sheet of paper and attach to the application.)
First Middle Last
First Middle Last
Do the child(ren) live with you?
□ Yes - Your role in the support case is the Custodial Parent (CP), if you are or are not the child’s parent
□
No - Your role in the support case is the Noncustodial Parent (NCP)
Do you currently receive or have you applied for enforcement services from North Carolina, another state, country
outside of United States of America (USA) or a private company for support of any of the children included in this
application?
□ No
□ Yes – State Country _________________________________
□ Name of private company ___________________________________________________________________________
Do you currently employ an attorney or private collection agency for child support?
□ No
□ Yes – Attorney or Agency Name Phone No. ( ) — _______
Attorney or Agency Address _____________
______
If you are applying for child support services, may we contact you by email?
□
Yes
□
No
Applicant/Public Assistance Recipient Name (Print)
Applicant/Public Assistance Recipient Signature Date _____________
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SECTION 2 – CUSTODIAL PARENT/GUARDIAN INFORMATION
Name ______
First Middle Last Suffix (e.g. Jr.)
Maiden Name: (If applicable)
Alias Name: (If applicable)
_
Gender:
□ Male □ Female
Date of Birth:
/ / ___
Social Security No.:
_ — — ________
Language Preference: □ English
□ Spanish □ Other __________
Indicate any special assistance that may be
needed:
□ Hearing Impaired □ Visually Impaired
□ Other (Explain) _______________________
Race:
□ Black □ White □ Hispanic □ Asian □ Unknown
□ American Indian Reservation □ Other (Specify) ____
□
American Indian Non-Reservation
Mailing Address:
______ _____ ____
Street City State Zip
Residential Address:
______ _____ ____
Street City State Zip
Home Phone No.:
( ) — _______
Area Code/Number
Cell Phone No.:
( ) — ____
Area Code/Number
Work Phone No.:
( ) — _______
Area Code/Number
Email address: ____________ ______________________________________________
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is
reason that your information should not be shared with other participants in this case.
□ A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□ I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□
I have no concerns regarding domestic violence now.
ONLY complete the income section below if the applicant is the child(ren)’s parent. If applicant is NOT a parent, skip
this section and go to Section 3.
Is the custodial parent currently employed?
□ Yes - If yes, what is the employer’s name _____
Address ____________
Phone No. ( ) — ____
□ No - Previous employer ________________________________________________________ _ _____
Date employment ended / / Reason ________________________ _ _____
Usual occupation _____
Income Sources - check all that apply and list the amount(s) below:
□ Military □ Veterans □ Social Security □ Other Retirement □ Unemployment
□ Other Income/Assets not listed above ____________________________________________________ _____
Amount (monthly gross)
Source (list income source)
$ ________________
$ ________________
Total Monthly gross income amount $ __________________________________________________________________
$ 0.00
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SECTION 3 – CHILD NO. 1
Complete Section 3 for
EACH
child for whom services are requested. If additional space is needed, list the information on a
separate sheet of paper and attach to the application.
Name
First Middle Last Suffix (e.g. Jr.)
Gender:
□ Male □ Female
Date of Birth:
/ / ___
Social Security No.:
_ — — ________
Language Preference: □ English
□ Spanish □ Other __________
Indicate any special assistance that may be
needed:
□ Hearing Impaired □ Visually Impaired
□ Other (Explain) _______________________
Race:
□ Black □ White □ Hispanic □ Asian □ Unknown
□ American Indian Reservation □ Other (Specify) ____
□ American Indian Non-Reservation
What is your relationship to this child?
Does the child live with you?
□
Mother
□ Father
□ Alleged Father
□ Other (Specify relationship)
_____________
□
No – If no, with whom does the child live?
_
Address __
Phone No. ( ) — _______________
□ Yes – If yes,
• How many nights per year does the child spend in the home? _______
• How long has the child been in the home? __ __Years ___ _Months
Does this child receive: (Select all that apply)
□ TANF/Work First □ Medicaid □ Health Choice □ Foster Care □ Subsidized Child Care
□ Social Security benefits – if yes, □ SSI or □ SSA (disability)
□ Veterans Administrative (VA) Dependent benefits – if yes, veteran’s name
List name(s) of parent(s) from whom support is being
requested:
Parent 1 _________ ___
Parent 2 ______
List name(s) of parent(s) as shown on child’s birth certificate:
Parent 1 ____
Parent 2 _ ___
Was the child’s mother married to anyone when the
child was conceived or born?
□ No
□ Yes – to whom: ______
Was the child born during the marriage of the parents?
□ No - If no, was an Affidavit of Parentage completed?
If yes, in what state? __________ ______________
□ Yes - If yes, attach the birth certificate
City, state, county and country where child was
conceived:
City: State: ____ County: _______ _____
Country: ______________________________________
City, state, county and country of the child’s birth:
City: State: ______ County: _______________________
Country: ___________________________________________
Has paternity testing been completed for this child and
parents?
□ No □ Yes - Date / / ____________
Results __________________________________________
(Attach a copy of the results)
Has paternity been established by:
□ Court Order □ Voluntary Acknowledgement □ Other
□ No □ Yes - Date / _ / _________________
County State ___
(
Attach copy/other documentation)
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What was the parent’s relationship status at the time of the child’s birth?
Date
Location (city/county/state)
□ Married / / ___
□ Separated / / ___
□ Divorced / / ___
□ Never married to each other
Does this child have health care coverage: (Select all that apply)
□ No
□ Yes - If yes, complete information below (Attach copy of insurance card or other verification of coverage. If additional space
is needed, list the information on a separate sheet of paper and attach to the application)
□ Medicaid □ Health Choice □ Medical □ Dental □ Vision □ Pharmacy □ Other Insurance
Insurance Provider ___
Name of Policy Holder
Policy Holder Relationship to the Child
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SECTION 3 – CHILD NO. 2
Complete Section 3 for
EACH
child for whom services are requested. If additional space is needed, list the information on a
separate sheet of paper and attach to the application.
Name
First Middle Last Suffix (e.g. Jr.)
Gender:
□ Male □ Female
Date of Birth:
/ / ___
Social Security No.:
_ — — ________
Language Preference: □ English
□ Spanish □ Other __________
Indicate any special assistance that may be
needed:
□ Hearing Impaired □ Visually Impaired
□ Other (Explain) _______________________
Race:
□ Black □ White □ Hispanic □ Asian □ Unknown
□ American Indian Reservation □ Other (Specify) ____
□ American Indian Non-Reservation
What is your relationship to this child?
Does the child live with you?
□
Mother
□ Father
□ Alleged Father
□ Other (Specify relationship)
________
□
No – If no, with whom does the child live?
_
Address __
Phone No. ( ) — _______________
□ Yes – If yes,
• How many nights per year does the child spend in the home? _______
• How long has the child been in the home? __ __Years ___ _Months
Does this child receive: (Select all that apply)
□ TANF/Work First □ Medicaid □ Health Choice □ Foster Care □ Subsidized Child Care
□ Social Security benefits – if yes, □ SSI or □ SSA (disability)
□ Veterans Administrative (VA) Dependent benefits – if yes, veteran’s name
List name(s) of parent(s) from whom support is being
requested:
Parent 1 _________ ___
Parent 2 ______
List name(s) of parent(s) as shown on child’s birth certificate:
Parent 1 ____
Parent 2 _ ___
Was the child’s mother married to anyone when the
child was conceived or born?
□ No
□ Yes – to whom: ______
Was the child born during the marriage of the parents?
□ No - If no, was an Affidavit of Parentage completed?
If yes, in what state? __________ ______________
□ Yes - If yes, attach the birth certificate
City, state, county and country where child was
conceived:
City: State: ____ County: _______ _____
Country: ______________________________________
City, state, county and country of the child’s birth:
City: State: ______ County: _______________________
Country: ___________________________________________
Has paternity testing been completed for this child and
parents?
□ No □ Yes - Date / / ____________
Results __________________________________________
(Attach a copy of the results)
Has paternity been established by:
□ Court Order □ Voluntary Acknowledgement □ Other
□ No □ Yes - Date / _ / _________________
County State ___
(
Attach copy/other documentation)
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What was the parent’s relationship status at the time of the child’s birth?
Date
Location (city/county/state)
□ Married / / ___
_____
□ Separated / / ___ _____
□ Divorced / / ___ _____
□ Never married to each other
Does this child have health care coverage: (Select all that apply)
□ No
□ Yes - If yes, complete information below (Attach copy of insurance card or other verification of coverage. If additional space
is needed, list the information on a separate sheet of paper and attach to the application)
□ Medicaid □ Health Choice □ Medical □ Dental □ Vision □ Pharmacy □ Other Insurance
Insurance Provider ___ _____
Name of Policy Holder _____
Policy Holder Relationship to the Child _____
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SECTION 4 – NONCUSTODIAL PARENT INFORMATION NO. 1
Name ____
First Middle Last Suffix (e.g. Jr.)
Alias Names:
(If applicable
)
Name(s) of child(ren) for this noncustodial parent:
Gender:
□ Male □ Female
Date of Birth:
/ / ___
Social Security No.:
_ — — ___ _ ____
Language Preference: □ English
□ Spanish □ Other ______________
Indicate any special assistance that may be
needed:
□ Hearing Impaired □ Visually Impaired
□ Other (Explain) _________________________
Race:
□ Black □ White □ Hispanic □ Asian □ Unknown
□ American Indian Reservation □ Other (Specify) ________
□ American Indian Non-Reservation
Birthplace:
City State
_________ ___
County
__________________
Country
______________________________
Height: ___________
Weight: ____
Identifying Marks:
Hair Color:
□ Bald □ Blond
□ Black □ Brown
□ Gray □ Red
□ Unknown
Eye Color:
□ Black □ Brown
□ Blue □ Gray
□ Green □ Hazel
□ Unknown
Mailing Address:
__ _ __
Street City State Zip
Residential Address:
__ _ __
Street City State Zip
Home Phone No.:
( ) — ________
Area Code/Number
Cell Phone No.:
( ) — _____
Area Code/Number
Work Phone No.:
( ) — _______
Area Code/Number
Email address: ____________ ___ _____________________________________________
Does the noncustodial parent have a driver license?
□
No
□
Yes – Driver License Number __ _____
State _____
Does the noncustodial parent have a vehicle?
□
No
□
Yes – Vehicle Make/Model/Year __ _____
______________________________________________________________________________________________________________________________________
Noncustodial parent’s father name: ______
Noncustodial parent’s mother name: ______
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What is the noncustodial parent’s current marital status?
□ Married - Date of marriage __ / / ___ Name of Spouse
□ Separated - Date of separation / / ___ Name of Spouse _______
□ Divorced - Date of divorce / / ___ Name of Spouse ______________
If multiple marriages/divorces, list dates and name of spouse for each
Is the noncustodial parent in the military?
□ No
□ Yes – If yes, which branch of the military:
□ Air Force □ Air Force National Guard □ Army □ Army National Guard □ Marine Corps □ Navy
What is his/her current military status:
□ Active duty □ Reserve □ Retired □ Separated □ AWOL □Unknown
What is his/her last known duty station?
Does the noncustodial parent have an arrest record?
□ No
□ Yes – If yes, when was the noncustodial parent arrested?
What city and state was the noncustodial parent arrested?
Is the noncustodial parent currently on parole/probation? □ No □ Yes – If yes, where?
Is the noncustodial parent currently incarcerated? □ No □ Yes – If yes, where?
Is the noncustodial parent currently on work release? □ No □ Yes – If yes, where?
Is the noncustodial parent currently employed?
□ Yes - If yes, what is the employer’s name
Address
Phone No. ( ) - ___________
□ No - Last known employer ________________________________________________________
Date employment ended / / Reason ________________________
Usual occupation _ ________
Select the noncustodial parent’s income sources - check all that apply and list the amount(s) below:
□ Military □ Veterans □ Social Security □ Other Retirement □ Unemployment
□ Other Income/Assets not listed above ____________________________________________________ _ _______
Amount (monthly gross)
Source (list income source)
$ ________________
$ ________________
$ ________________
Total Monthly gross income amount $ ____ ___________________________________________________________
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Is there a support order or agreement?
(If additional space is needed, list information on a separate sheet of paper and attach to the application)
□ No □ Yes - If yes, select the type of support and complete the requested information:
□ Court Order □ Medical Support □ Spousal Support □ Voluntary Agreement (Attach copy of order or agreement)
Court docket number Order effective date ____ County/State _____________
Amount ordered $ per Amount past due $ _____________
Payor ________________________ _________ Recipient __________________________ _____________
Child(ren) included in order _______________________________________________________ _____________
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is
reason that your information should not be shared with other participants in this case.
□ A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□ I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□ I have no concerns regarding domestic violence now.
Below, tell us any additional information about the noncustodial parent.
____
____ ____ ____ ____ ____
____ ____ ____ ____ ____
____
____
____
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SECTION 4 – NONCUSTODIAL PARENT INFORMATION NO. 2
Additional Parent - Complete ONLY if this application for services is for more than one noncustodial parent. If
additional space is needed, list information on a separate sheet of paper and attach to the application.
Name _____
First Middle Last Suffix (e.g. Jr.)
Alias Names:
(
If applicable)
Name(s) of child(ren) for this noncustodial parent:
__
__
Gender:
□ Male □ Female
Date of Birth:
/ / ___
Social Security No.:
_ — — ____ ____
Language Preference: □ English
□ Spanish □ Other _______________
Indicate any special assistance that may be
needed:
□ Hearing Impaired □ Visually Impaired
□ Other (Explain) _________________________
Race:
□ Black □ White □ Hispanic □ Asian □ Unknown
□ American Indian Reservation □ Other (Specify) _________
□ American Indian Non-Reservation
Birthplace:
City State
_________ ___
County
__________________
Country
______________________________
Height: ___________
Weight: ____
Identifying Marks:
Hair Color:
□ Bald □ Blond
□ Black □ Brown
□ Gray □ Red
□ Unknown
Eye Color:
□ Black □ Brown
□ Blue □ Gray
□ Green □ Hazel
□ Unknown
Mailing Address:
__ _ __
Street City State Zip
Residential Address:
__ _ __
Street City State Zip
Home Phone No.:
( ) — ________
Area Code/Number
Cell Phone No.:
( ) — _____
Area Code/Number
Work Phone No.:
( ) — _______
Area Code/Number
Email address: ____________ ___ _____________________________________________
Does the noncustodial parent have a driver license?
□
No
□
Yes – Driver License Number __ _____
State _____
Does the noncustodial parent have a vehicle?
□
No
□
Yes – Vehicle Make/Model/Year __ _____
______________________________________________________________________________________________________________________________________
Noncustodial parent’s father name: ______
Noncustodial parent’s mother name: ______
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What is the noncustodial parent’s current marital status?
□ Married - Date of marriage __ / / ___ Name of Spouse _______
□ Separated - Date of separation / / ___ Name of Spouse ______________
□ Divorced - Date of divorce / / ___ Name of Spouse _____________________
If multiple marriages/divorces, list dates and name of spouse for each _______
_______
Is the noncustodial parent in the military?
□ No
□ Yes – If yes, which branch of the military:
□ Air Force □ Air Force National Guard □ Army □ Army National Guard □ Marine Corps □ Navy
What is his/her current military status:
□ Active duty □ Reserve □ Retired □ Separated □ AWOL □Unknown
What is his/her last known duty station? ________
Does the noncustodial parent have an arrest record?
□ No
□ Yes – If yes, when was the noncustodial parent arrested?
What city and state was the noncustodial parent arrested?
Is the noncustodial parent currently on parole/probation? □ No □ Yes – If yes, where?
Is the noncustodial parent currently incarcerated? □ No □ Yes – If yes, where?
Is the noncustodial parent currently on work release? □ No □ Yes – If yes, where?
________
Is the noncustodial parent currently employed?
□ Yes - If yes, what is the employer’s name ______
Address ______
Phone No. ( ) - _______________
□ No - Last known employer ________________________________________________________ ______
Date employment ended / / Reason ________________________ ______
Usual occupation _ ________ ______
Select the noncustodial parent’s income sources - check all that apply and list the amount(s) below:
□ Military □ Veterans □ Social Security □ Other Retirement □ Unemployment
□ Other Income/Assets not listed above ____________________________________________________ _ _______
Amount (monthly gross)
Source (list income source)
$ ________________
$ ________________
$ ________________
Total Monthly gross income amount $ ____ ___________________________________________________________
0.00
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Is there a support order or agreement?
(If additional space is needed, list information on a separate sheet of paper and attach to the application)
□ No □ Yes - If yes, select the type of support and complete the requested information:
□ Court Order □ Medical Support □ Spousal Support □ Voluntary Agreement (Attach copy of order or agreement)
Court docket number Order effective date ____ County/State _____________
Amount ordered $ per Amount past due $ _____________
Payor ________________________ _________ Recipient __________________________ _____________
Child(ren) included in order _______________________________________________________ _____________
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is
reason that your information should not be shared with other participants in this case.
□ A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□ I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□ I have no concerns regarding domestic violence now.
Below, tell us any additional information about the noncustodial parent.
____
____ ____ ____ ____ ____
____ ____ ____ ____ ____
____
____
____
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SECTION 5 – ATTACHMENTS
Check all items that are attached to this application. If an item is not listed, check “Other” and list the item(s) attached
(including any documents, orders, photos, statements, etc.)
Copy of the birth certificate and Social Security card for each child included in this application
Copy of your Photo ID (e.g. driver’s license)
Photo of the child’s other parent(s)
Verification of your income, not required if you are not the child’s parent (e.g. pay stubs, tax returns)
Copy of the marriage certificate of the child’s parents (if not available, provide dates of marriage and/or other
verification of marital status of the children’s parents)
Copies of any legal documents related to the child(ren) included in this application (if not available, list the date,
county, state of filing and court case number for the documents):
• Affidavit of Parentage
• Paternity order
• Child support and/or spousal support Order (initial and all modification orders)
• Voluntary agreement for child support
• Divorce decree and/or separation agreement
• Order terminating parental rights
• Domestic violence protective order
Other
SECTION 6 – OTHER INFORMATION
Provide additional information that may assist Child Support Services in processing your application.
SECTION 7 – CERTIFICATION STATEMENT
I hereby certify that I have provided all requested information that is available to me and that it is true and correct to
the best of my knowledge. I agree to meet all obligations and duties assigned to me.
Print Legal Name
Signature of Applicant Date
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(APPLICANT COPY)
North Carolina Child Support Services (NCCSS) administers the North Carolina child support program under Title IV-D of the Social
Security Act. Services are available to a parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and
judicial officials. The child support program’s goal is to provide the best possible services to families for children. Whether you are
making an application for child support services as a recipient of assistance from other social services programs (Temporary
Assistance to Needy Families [TANF], Foster Care and/or Medicaid) or requesting child support services as a non-public assistance
applicant, your involvement, information, and contributions are important and required.
NORTH CAROLINA CHILD SUPPORT SERVICES INFORMATION
PROGRAM SERVICES
NCCSS provide child support services to assist families in meeting their financial obligations for children. There is no residency or
citizenship eligibility requirement for services. Depending on the circumstances of each family, one or more of the following
services may be appropriate:
• Location of noncustodial parent – State, federal, local and national resources are used to assist in collecting information
about a parent, such as their residence, employment and/or financial assets.
• Paternity establishment – A determination of parental legal responsibility for the child(ren) is necessary before a parent
can be required to pay support. If a child’s parents were not married to each other at the time of the child’s birth,
arrangement of paternity testing may be offered to the parties, if appropriate.
• Support establishment – In North Carolina, support is determined using the guidelines established in State law. N.C. Child
Support Guidelines consider both parent’s monthly gross incomes, the amount of time the child spends with each parent
and various expenses. NCCSS seeks to establish a court order requiring a parent to provide child and/or medical support
for child(ren) based on the N.C. Child Support Guidelines.
• Collection of support – Child support payments through bank draft, money order or check are sent to N.C. Child Support
Centralized Collection (NCCSCC). A large amount of child support payments is deducted from a parent’s wages and sent to
NCCSCC by an employer. North Carolina Child Support Services records and disburses all collected child support payments
to families by personal direct deposit into a bank account or debit card.
• Enforcement of support – Enforcement of an established or existing child support, spousal support, and/or medical
support court order is met by wage withholding, tax refund offset, liens, professional license/passport revocation, credit
reporting, court action, or other collection remedies. Support orders may be reviewed for modification
(increase/decrease) every three years or more often, if warranted.
NCCSS does not provide the following services: custody, visitation, or the establishment of spousal support obligations.
PROGRAM FEES
• Application Fee – Families receiving public assistance (TANF, Medicaid and/or Foster Care) are not charged an application
fee for support services. Families that are not receiving public assistance are charged a non-refundable application fee of
up to $25. If the applicant’s income is below 100% of the Federal Poverty Guidelines, a reduced application fee of $10 is
available. Contact your local child support agency for additional information about qualifying for the reduced application
fee. The application fee must be paid before support services can begin.
• Annual Services Fee – Each year, non-public assistance child support cases (cases that public assistance has never been
provided) are charged a non-refundable $25 fee after at least $500 in support payments has been paid to the family. The
annual service fee is automatically deducted from support payments made to the custodian, and is collected during each
federal fiscal year, from Oct. 1 through Sept. 30.
• Administrative Offset Fees – Department of Revenue or Internal Revenue Service (IRS) fees may be deducted from the
noncustodial parent’s tax refund(s) collected for past due support before being disbursed as a support payment to the
custodial parent. The noncustodial parent is credited with the full tax refund(s) amount collected.
• Legal Fees – Agency attorney services and court fees are paid by the agency, or may be charged to the noncustodial parent
as allowed by law. There is no cost to a custodial parent for legal fees when a court action is established by the agency.
However, any costs for private legal services obtained by either parent are the parent’s responsibility.
PROGRAM DISTRIBUTION
• Distribution of Support – Support payments are disbursed in accordance with federal regulations. Support payments are
paid toward all the noncustodial parent’s current support obligations first, except for tax refund offsets which are paid
toward any state debt owed first. Support payments are deposited to an agency-issued debit card or personal bank
account. Support payments exceeding the noncustodial parent’s current support obligations are applied to any past due
support.
• Tax Refund Offset – Support payments received from a joint tax return offset may not be distributed for up to six months.
The IRS may adjust a refund amount, which may require the custodial parent to return some or all a support payment
received from a tax refund. Tax refund offsets are applied to eligible cases annually.
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OTHER PROGRAM POLICIES & INFORMATION
• Disclosure of SSN – Social Security numbers are obtained and kept on file at the local child support agency to locate and
identify individual’s assets for the purposes of establishing, modifying and enforcing child support obligations. Enrolling a
child in health care coverage may require the release of the child’s Social Security number and mailing address to the other
parent’s employer, or the release of the child’s Social Security number to the other parent.
• Confidentiality – Child support case records are not public records. The information in your case may be discussed with or
given to other state child support services and or other public agencies that can legally receive such information and to the
other parent or his/her attorney to the extent required by law. If the local child support agency is notified that
family/domestic violence is an issue, the local child support agency must take additional steps to further safeguard
information.
• Nondiscrimination – In accordance with the Civil Rights Act of 1964, NCCSS ensures that all individuals are treated equally,
and that no person is discriminated against in the selection or eligibility to receive services in any manner prohibited by
law.
• Intergovernmental Cases – Federal law requires every state to enact the Uniform Interstate Family Support Act (UIFSA)
2008 to aid states in working together to establish and enforce child support orders. Every state and many tribes, foreign
countries, territories or tribunals have an agency to enforce child support orders. If parents do not live in the same state,
although laws differ, child support agencies work with each other to locate parents and to establish and enforce orders.
• Case Management Decisions – Local child support agencies determine the appropriate services for child support cases, as
well as the way services are delivered by the agency. Reasonable and necessary actions to best serve your case will be
considered; however, specific time frames or results cannot be guaranteed.
APPLICANT RIGHTS & RESPONSIBILITIES
All applicants: either parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and judicial officials in
a child support case have the following rights and responsibilities:
Rights
• To make an application for child support services at a local child support agency
• To be provided information about the status of your child support case
• To establish an account on the eChild Support website (www.ncchildsupport.com) to access case information
• To receive notice of all pending court actions, and to be provided copies of all court orders from court hearings related to
your child support case
• To request that the support order be reviewed or modified at least every three years
• To request a review of case management or distribution of funds in your case
• To hire a private attorney (at your own cost) to represent your interests in the child support case. The child support
attorney represents the child support agency and cannot represent you in child support or other legal matters regarding
the child, such as custody and visitation
Responsibilities
• To provide the child support agency information that may help in the progression of the child support case
• To attend any appointments and/or hearings for which you have been provided notice that your participation is needed
• To notify the child support agency of changes in your address and/or employment
• To notify the child support agency if the child being provided services:
o Is no longer in your custody
o Graduates or ceases to attend high school
• To repay any payments received in error
Additional information about the Child Support program is available at www.ncchildsupport.com
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Child Support Services APPLICATION FOR SERVICES Thank you (Henderson County)

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Completed 21 January 2021

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