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Distribution: Child Support Customer Service (original) Client, TDHS Central Office (copy)
RDA: 2124
HS-2755 (Rev. 01-19)
Page 1 of 1
Tennessee Department of Human Services
Client Complaint
(Federal Regulation 45 CFR 303.35 Administrative Complaint Procedure)
If you have a child support case with Tennessee’s child support program, and you believe that you have not
been provided with the level or quality of service to which you are entitled under the rules and regulations of
the Tennessee Department of Human Services or the Federal Office of Child Support Enforcement, you
may wish to file a complaint by completing the following information and mailing it to:
Office of the Assistant Commissioner
Child Support Program
Tennessee Department of Human Services
505 Deaderick Street, 17th Floor Nashville, TN 37243-1403
You may also sign and submit this form electronically. Submit by clicking the “Submit” button at the bottom
o
f the page. Completion of this form does not replace any administrative hearing or appeal rights that you
may be entitled. Please provide the following information as completely as you can.
D
ate:
Name:
Social Security Number:
Your Address:
Your Daytime Phone Number:
Your Email Address:
TCSES Case ID Number (If Known):
Location of the child support office you use:
Other Parent’s Name:
Other Pa
rent’s Social Security Num
ber:
My complaint, question, or concern is:
click to sign
signature
click to edit
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