Fillable FDVCSAP BCSE Applicationand Income Withholding (West Virginia Supreme Court of Appeals)

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FDVCSAP BCSE Applicationand Income Withholding (West Virginia Supreme Court of Appeals)

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FDVCSAP: Bureau for Child Support Enforcement Application and Income Withholding Form
Revision Date: 08/09/2019; (previously SCA-DV-FC-1202 and SCA-FC-113)
Page 1 of 2
BUREAU FOR CHILD SUPPORT ENFORCEMENT
APPLICATION AND INCOME WITHHOLDING FORM
This Form MUST Be Completed In All Cases Involving Minor Children or Spousal Support!
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 box if a Support Order in NOW in effect.
PETITIONER
Full Name:
Birth Date:
/ /
SSN:
- -
Male /
Female 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 No:
( )
-
Driver's License No:
RESPONDENT
Full Name:
Birth Date:
/ /
SSN:
- -
Male /
Female 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)
Driver's License No:
Dependents: (List full name, sex, birth date, social security #, and custodian for each dependent)
Name Sex Date of Birth Social Security No. Custodian
/
/ - -
/ / - -
/ / - -
/ / - -
Income Withholding (List complete address of the employer or other source of income to which an
Income Withholding Notice should be sent.)
Pursuant to the Privacy Act [5 U.S.C. 522a], the Bureau for Child Support Enforcement (BCSE) is required to inform
you of the following: (a) that the request for your social security number is a mandatory requirement pursuant to the
Social Security Act [42 U.S.C. 466(a)(13)]; and (b) the BCSE will use this information only in connection with the State's
child support enforcement program for purposes of establishing paternity and establishing, modifying, and enforcing
support obligations. CONTINUED ON NEXT PAGE
Daytime Phone No:
( )
-
FDVCSAP: Bureau for Child Support Enforcement Application and Income Withholding Form
Revision Date: 08/09/2019; (previously SCA-DV-FC-1202 and SCA-FC-113)
Page 2 of 2
Check this box if you or your children currently receive TANF benefits.
Check this box if you currently receive, or have applied for DHHR's Child Support Services.
IF YOU CHECKED any of the two 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 two 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
Check this box if YOU WOULD FEAR FOR YOUR SAFETY, or THE SAFETY OF YOUR
CHILDREN if your address and telephone number are disclosed.
Date
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FDVCSAP BCSE Applicationand Income Withholding (West Virginia Supreme Court of Appeals)

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Completed 26 July 2020

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