Fillable FC113 Untitled (West Virginia Supreme Court of Appeals)

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FC113 Untitled (West Virginia Supreme Court of Appeals)

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__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________
______________________________________________________________________________
___
___
BUREAU FOR CHILD SUPPORT ENFORCEMENT
APPLICATION AND INCOME WITHHOLDING FORM
This Form MUST Be Completed In All Cases Involving Minor Children or Spousal Support!
County: _________________________ Civil Action No. ____________
Withholding services will begin immediately when the Bureau for Child Support Enforcement
receives this completed application, which MUST be accompanied by a copy of the current
Support Order IF one is now in effect.
___
Check this blank if a Support Order is NOW in effect.
Petitioner
Full Name: _________________________ Birth date: _______ SSN: ___________
Sex: _____ Relationship to children involved in this case: _______________________________
Residence Address: _____________________________________________________________
(List complete physical address: county; city; street #; apt. #; zip code.)
Mailing Address: _____________________________________________________________
(List mailing address ONLY if different from physical address.)
Daytime phone #: ____________________ Driver’s License #: ______________________
Respondent Full Name: _________________________ Birth date: _______ SSN: ___________
Sex: _____ Relationship to children involved in this case: _______________________________
Residence Address: _____________________________________________________________
(List complete physical address: county; city; street #; apt. #; zip code.)
Mailing Address: _____________________________________________________________
(List mailing address ONLY if different from physical address.)
Daytime phone #: ____________________ Driver’s License #: ______________________
Dependents
( List full name; sex; birth date; social security #; and custodian for each dependent.)
Income Withholding (List complete address of the employer or other source of income to which an Income
Withholding Notice should be sent.
)
Check this blank if YOU WOULD FEAR FOR YOUR SAFETY, or THE SAFETY OF
YOUR CHILDREN if your address and telephone number are disclosed.
Check this blank if you currently receive TANF benefits.
CONTINUE ON NEXT PAGE
SCA-FC-113 (12/01) Bureau for Child Support Enforcement Application Page 1 of 2
___ Check this blank if you or one of your children currently receives a DHHS Medical Card.
___
Check this blank if you currently receive, or have applied for DHHS Child Support Services.
IF YOU CHECKED any of the four items immediately above, skip to the end of the form, SIGN
on the line provided, and you are done.
IF YOU DID NOT CHECK any of the four items immediately above, YOU MUST CONTINUE!
___ I understand that unless otherwise directed by the court, any court ordered support MUST be
collected by the BCSE through Income Withholding.
YOU MUST
CHOOSE ONE OF THE THREE FOLLOWING OPTIONS!
OPTION # 1.
___ I am applying for FULL SERVICES from the BCSE. I understand that full services include,
but are not limited to the following: *Collection and distribution of support payments.
*Collection and enforcement of support by income withholding. *Establishment and
enforcement of Support Orders. *Establishment of paternity. *Enforcement of Support Orders
through Federal and State Tax offsets, unemployment compensation intercepts, and workers’
compensation intercepts. *Location of parent(s). *Interstate services.
___
As an applicant for FULL SERVICES, I AGREE to comply with the following requirements:
1. I understand I MUST assist the BCSE to establish and enforce paternity, child support, and
medical support, and to collect child and spousal support. I understand this assistance may
include providing information about the non-custodial parent, and responding promptly and
completely to requests from the BCSE. I understand I may be required to testify as a witness in
court, or in other proceedings.
2. I understand that I am free to pursue legal actions through a private lawyer, but that I must
inform the BCSE if I do this.
3. I understand that I MUST repay all money received in error to which I am not entitled.
OPTION # 2.
___
I am applying for Income Withholding Services ONLY.
OPTION # 3.
___
I DID NOT CHECK Option #1 or Option #2. I do not want services from the BCSE at this
time.
___ I understand that even though I have not requested services at this time, I can request services
at any time by applying at the BCSE office in the county in which I live.
I CERTIFY that I have read and understand all statements on this application, and that all
information I have provided is TRUE and ACCURATE to the best of my knowledge.
Signature: _______________________________________________ Date: ________________
SCA-FC-113 (12/01) Bureau for Child Support Enforcement Application Page 2 of 2
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FC113 Untitled (West Virginia Supreme Court of Appeals)

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Completed 25 July 2020

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