Fill - Free fillable Formcir Petition To ModifyCS Pkt (Metropolitan Government of Nashville & Davidson County, Tennessee) PDF form

FACTS FOR YOU ABOUT THE

PETITION TO MODIFY CHILD SUPPORT

The Circuit Court Clerk’s Office can assist you with completing a Petition to Modify Child Support

form. The first hearing will be held at Child Support Services at 8:30 a.m. If no agreement is

reached at the first hearing, you will be on a 1:30 p.m. Court docket at the Historic Courthouse in

front of the assigned Judge.

Please complete the Support Intake Sheet, Petition to Modify Child Support and Application –

if handwritten, please print legibly – include additional page(s) if needed – and return ALL

DOCUMENTS to this office, signed and notarized, along with the appropriate filing fee:

 $119.00 ($77.00 fee + $42.00 for service of process in Davidson County);

 $88.85 ($77.00 fee + $11.85 for certified mail service);

 $97.00 ($77.00 fee + $20.00 check to Secretary of State for out-of-state service); or

 $119.00 ($77.00 fee + $42.00 money order to Sheriff for out-of-county service).

In accordance with Supreme Court Rule 29, if you meet the federally mandated

poverty guidelines (click here to see Guidelines) for family income, you may

qualify to proceed as an indigent party (click here for Affidavit of Indigency). If

you qualify, this excuses the advanced filing fee; however, this may not excuse

your payment of the fee as the Court may tax court costs to you at the hearing.

Once filed, the Petition is sent to the assigned Court for review. The Judge will either sign or deny

the Show Cause Order. If the Judge denies the Show Cause Order, you will need to know how to

proceed with setting your Petition for hearing after it is served on Respondent. If the Judge

approves the Show Cause Order, you will receive a copy of the Order with the hearing date

and service of process will be issued to the other party. Please contact our office

approximately one (1) week prior to the hearing to confirm if the Respondent has been served.

If the Respondent is not served by the Court date, then your case will not be on the docket for that

day. Please contact this office at 615-862-5181 with a better address and fees for another attempt at

service. We will try to serve that person again and a new Court date will be set.

If additional attempts at service are required, $40 will be needed for Davidson County service.

***Fees may be paid by phone with valid credit/debit card***

YOU WILL RECEIVE A COPY OF THE PENDING HEARING DATE BY MAIL.

1

st

HEARING: Child Support Services

44 Vantage Way

Suite 300

Nashville, TN 37228

1

st

HEARING TIME: 8:30 a.m.

2

nd

HEARING: Historic Courthouse

(if necessary) 1 Public Square, 6

th

Floor

Nashville, TN 37201

2

nd

HEARING TIME: 1:30 p.m.

PRINT PACKET

Petition to Modify Child Support Revised 9/27/16

SUPPORT INTAKE SHEET

Petitioner

vs. Case No.

Respondent

Information about you (Petitioner):

Name:

Date of Birth:

Address:

Telephone:

Employer:

Employer Address:

Employer Telephone:

Information about Respondent:

Name:

Date of Birth:

Address:

Telephone:

Employer:

Employer Address:

Employer Telephone:

Petition to Modify Child Support 1 Revised 9/27/16

T.C.A. §36-5-405

IN THE CIRCUIT COURT FOR DAVIDSON COUNTY, TENNESSEE

Petitioner

vs. Case No.

Respondent

PETITION TO MODIFY CHILD SUPPORT

Petitioner, , under T.C.A. Title

36, Chapter 5, states:

1. Petitioner is a resident of County, Tennessee, and

lives at .

2. Respondent is a resident of County, Tennessee, and

lives at .

3. Respondent is employed at .

4. The child(ren) for whom support is sought is(are):

Names Birthdates

5. This(these) child(ren) reside(s) with .

6. Petitioner’s relationship to the(se) child(ren) is .

7. Petitioner/Respondent is obligated to pay support for this(these) child(ren)

because (check appropriate section):

a. Petitioner/Respondent is legal parent by virtue of birth during

marriage to (ex-spouse name)

on (date of marriage) .

b. Court Order of Court on (date) _______________

(Order of paternity, legitimization, divorce, adoption, reciprocal).

8. Petitioner seeks to (check appropriate item):

a. Modify support:

Petition to Modify Child Support 2 Revised 9/27/16

T.C.A. §36-5-405

(1) by increasing support due to a substantial and material

change of circumstances.

(2) by decreasing support due to a substantial and material

change of circumstances which makes Petitioner unable

to pay the support s/he is obligated to pay.

b. Other:

SO THE PETITIONER REQUESTS:

1. That proper process issue and an Order issue requiring the Respondent to

appear and show cause in accordance with the requests of this Petition.

2. That the Court order (check appropriate item(s)):

a. An increase in child support.

b. A decrease in child support.

c. Other:

.

3. For general relief.

PETITIONER

PURSUANT TO T.C.A. §29-1-107, THIS IS PETITIONER’S FIRST

APPLICATION FOR EXTRAORDINARY PROCESS IN THIS CAUSE.

Petition to Modify Child Support 3 Revised 9/27/16

T.C.A. §36-5-405

STATE OF TENNESSEE )

COUNTY OF DAVIDSON )

, Petitioner, being first duly sworn, has

read the foregoing Petition, knows the contents thereof, and states that the same is true

and correct to the best of Petitioner's knowledge, information and belief.

PETITIONER

Sworn to and subscribed before me, this _ day of __ , 20_____.

NOTARY PUBLIC / CLERK

My Commission Expires:

To request an ADA accommodation, please contact Dart Gore at 880-3309.

STATE OF TENNESSEE

DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR CHILD SUPPORT SERVICES

It is this agency’s desire to act in the best interest of you and your child(ren) at all times. Therefore, we want to give you some

important information regarding how your case will be handled.

INFORMATION YOU NEED TO KNOW

 You must notify us immediately if you move or change your telephone number.

 Your cooperation is required.

 You must return any money sent to you in error.

 You must notify us in writing if you wish to cancel services.

WE CAN ATTEMPT TO

 Locate a parent whose whereabouts are unknown,

 Establish paternity for a child,

 Establish and enforce court orders for child support payments, unpaid medical bills, and/or medical insurance,

 Review and modify child support orders, and

 Collect child support arrears using a variety of enforcement methods, including intercepting federal income tax refunds.

WE CANNOT

 Guarantee that our attempts to establish or enforce child support will be successful,

 Handle matters that are not related to child support such as divorce, visitation or custody disputes, or

 Give your case priority over any other cases we have.

AFTER WE RECEIVE YOUR COMPLETED APPLICATION, WE WILL

 Review your case,

 Decide the proper action to take on your case, and

 Make every effort to provide the needed service.

IN ADDITION

 We will contact you if we need additional information from you, and to inform you of appointments and court hearing

dates.

 Your signature on the application form indicates your agreement that the agency may file a legal action in your case and

may close your case if you do not cooperate.

 Our attorneys represent the State of Tennessee. They will help provide you with child support services, but they do not

represent you or any other individual.

 Case information will be given out only for child support purposes.

 All child support payments will be processed through the State Disbursement Unit in Nashville, Tennessee.

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State of Tennessee

Department of Human Services

Information Gathering Letter

In accordance with federal law and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the

basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, contact HHS. Write HHS, Director, Office for Civil Rights,

Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (Voice) or (202) 619-3257 (TTY). HHS are equal

opportunity providers and employers. You may also write Tennessee, DHS, Civil Rights Compliance Officer, Citizens Plaza Building, 400 Deaderick Street

15

th

Floor, Nashville, TN 37243, (615) 313-4748.

NOTE: Each individual's Social Security number (SSN) is a critical part of case processing. Based on section 466(a)(13) of the Social Security Act [42

U.S.C. 666(a)(13)], you are required to disclose Social Security numbers to the child support agency. They will be used by the State's child support

enforcement program to locate individuals for the purposes of establishing paternity and establishing, modifying, and enforcing support obligations. It is

possible that your SSN and those of the child(ren) will be used to file interstate child support enforcement actions and to enroll the child(ren) as beneficiaries

of health insurance coverage, and, as such, may be released to the other parent. The alternate residential parent’s SSN is necessary to properly identify that

parent for the purpose of locating him/her, for submitting cases for the Treasury Offset Program, and for other child support enforcement activities.

The information requested in this application must be provided by every applicant for child support services, regardless of whether they are the primary

residential parent / caretaker or the alternate residential parent of the child(ren). If you are the primary residential parent (PRP) / caretaker, enter

information about yourself in Section II and enter information about the alternate residential parent in Section III. If you are the alternate residential

parent (ARP), enter information about the primary residential parent / caretaker in Section II and enter information about yourself in Section III.

If you were married when the child(ren) was born, or when the child(ren) was conceived, or within three hundred (300) days after the

marriage was terminated for any reason, Tennessee law states your husband is the legal father of your child(ren), and he will be

pursued for child support.

I. INFORMATION ABOUT THE APPLICANT FOR CHILD SUPPORT SERVICES

1. Are you

 The PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER of the child(ren) for whom services are requested

(The PRP is the parent with whom the child(ren) resides more than 50% of the time) NOTE: For the purpose of completing this application,

also check this box if the child(ren) for whom you are requesting services resides/reside with you exactly 50% of the time.

or

 The ALTERNATE RESIDENTIAL PARENT (ARP) of the child(ren) for whom services are requested

(The ARP is the parent with whom the child(ren) resides less than 50% of the time)

If you are the ALTERNATE RESIDENTIAL PARENT (ARP), are you applying for

 A review and modification of your support order, or

 To establish paternity for the child(ren)?

NOTE: Any application for child support services will result in this agency taking action as needed to enforce support obligations.

2. Are you under age 18 and unmarried?  Yes  No If yes, provide the following information about your parent or guardian:

Last Name: _______________________________________ First Name: ________________________ Middle Name: ____________________

Address: ___________________________________________________________________________________ __________________________

City: _______________________________________________ State: ____________________________ Zip: ________________________

Phone (Home): (______)____________________________ (Cell): (______)______________________ (Work): (_____)___________________

3. Do you have reason to believe that the ARP might try to harm you or the child(ren) if we try to contact him/her, or as the result of any action we

might take on your child support case?  Yes  No

If yes, please attach documentation, such as Police Report, Order of Protection, etc.

FOR STATE USE ONLY

Foster care worker’s name: Phone:

Approval date: Social Services Number: IVE Case Number:

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II. INFORMATION ABOUT THE PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER

If you are the primary residential parent (PRP) or caretaker of the child(ren), provide the following information about yourself.

If you are the alternate residential parent (ARP), complete this section with information about the primary residential parent (PRP) / caretaker.

1. Last Name: ___________________________________ First Name: _______________________________ Middle Name: _______________

Maiden Name: ________________________________

2. What is the caretaker’s relationship to the child(ren) (mother / father / grandmother / etc.)?

3. Identifying information for the primary residential parent (PRP) / caretaker

Date of Birth: ______/______/________ Social Security Number: ________-________-________ Sex: ______________

Email Address: ____________________________________________________ Would you like to opt in to Email Messaging:  Yes  No

Address of the primary residential parent (PRP) / caretaker

MAILING address: __________________________________________________________________________________________________

City: ______________________________________ State: ______________ Zip: _______________ County: _______________________

Phone (Home): (_____)______________________ (Cell): (_____)_______________________ (Work): (_____)_______________________

Would you like to opt in to Text Messages?  Yes  No If YES, which number do you want associated with Text Messages?  Home Cell

LIVING address: ___________________________________________________________________________________________________

City: ______________________________________ State: ______________ Zip: _______________ County: _______________________

How do you prefer your caseworker to contact you?  Mail  Email Home Cell Work

4. Primary residential parent (PRP)’s / caretaker’s employer: _________________________________________________________________ ___

Address: ____________________________________________________________________________ Phone: (______)__________________

City: ______________________________________________________ State: ____________________________ Zip: ______________

5. Has the primary residential parent (PRP) / caretaker ever been married to the alternate residential parent (ARP)?  Yes  No

If yes, provide any of the following information that applies:

Marriage Date: _______________________________________ County: __________________________ State: ____________________

Divorce Date: ______________________________________ County: __________________________ State: ____________________

Separation Date: ______________________________________ County: __________________________ State: ____________________

6. Is any other agency or attorney involved in pursuing child support at this time?  Yes  No

If yes, give the name of the agency/attorney: __________________________________________ Phone number: (_____)_____________ ___

Address: ___________________________________________________________________________ ________________________________

City: ________________________________________________ State: _____________________________ Zip: ______________________

Has there ever been ANY legal action involving this child(ren)?  Yes  No If yes, describe the action:______________________________

Answer questions # 7 and 8 only if you are the primary residential parent (PRP) / caretaker of the child(ren)

7. Do you currently receive, or have you ever received Medicaid benefits?  Yes  No

Do you currently receive, or have you ever received public assistance, Families First, benefits?  Yes  No

If yes, for what period of time? From : _________________________________ To: ___________________________________________

Did you receive these benefits in Tennessee?  Yes  No In which other state(s) did you receive these benefits? ___________________

8. Name, phone number and address of a person we can contact if we are not able to reach you.

Name: ____________________________________________________________________________________________________________

Phone number: (________)___________________________________________________ Relationship: ____________________________

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Address: ___________________________________________________________________________________________________________

City: ________________________________________________ State: _____________________________ Zip: ______________________

III. INFORMATION ABOUT THE ALTERNATE RESIDENTIAL PARENT (ARP)

If you are the alternate residential parent (ARP), provide the following information about yourself.

If you are the primary residential parent (PRP) / caretaker, provide the following information about the alternate residential parent (ARP) of the

child(ren).

If you were married when the child(ren) was born, or when the child(ren) was conceived, or any time during the 300 days before the birth of your

child(ren), Tennessee law states your husband is the legal father of your child(ren).

If you are applying for support from more than one alternate residential parent (ARP), you must complete a separate application for each alternate

residential parent (ARP). If different persons could possibly be the father of the same child(ren), make a note of this in Section V, Page 5 of this

application.

1. Last Name: First Name: Middle Name:

Maiden Name (if applicable):

2. Alias or nicknames: Last: First: Middle:

3. What is the alternate residential parent (ARP)’s relationship to the child(ren)?  Father  Mother

4. Phone number(s) for the alternate residential parent (ARP).

Home: (______)_________________________ Cell: (______)_______________________ Has ARP ever lived in Tennessee?  Yes  No

5. Address of the alternate residential parent (ARP):

Current or last known MAILING address: ________________________________________________________________________________

City: _______________________________________________ State: ____________________________ Zip: ______________________

Is mail delivered to this address?  Yes  No

Current or last known LIVING address: __________________________________________________________________________________

City: _______________________________________________ State: _____________________________ Zip: ______________________

Do you confirm the ARP lives here?  Yes  No

6. Is the alternate residential parent (ARP) self-employed?  Yes  No If yes, in what occupation? ______________________________

7. Alternate residential parent (ARP)’s current employer: ______________________________________________________________________

Address: _____________________________________________________________________ Work number: (______)________________

City: _______________________________________________ State: ___________________________ Zip: _______________________

Alternate residential parent (ARP)’s previous employer:______________________________________________________________________

Address: _____________________________________________________________________

City: _______________________________________________ State: ____________________________ Zip: _______________________

8. General information about the alternate residential parent (ARP)

Social Security number

Birthplace (city/county/state)

Date of birth

Approximate age

Driver’s license number (include state)

Sex

Race

Height

Weight

Hair color

Eye color

Photograph provided?

Distinguishing marks

Known disabilities

Email Address

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9. Is the alternate residential parent (ARP) currently in  jail  or prison ? If yes, provide the following information:

Name of the institution: _________________________________________________ Expected release date: ____________________________

Address: _____________________________________________________________________________________________________________

City:________________________________________________ State: _____________________________ Zip: _______________________

10. Is this alternate residential parent (ARP) on  probation  or parole? If yes, provide the following information:

Parole or probation officer’s name: ________________________________________________________________________________________

Address: ___________________________________________________________________ Phone number: (______)____________________

City: _______________________________________________ State: _____________________________ Zip: ________________________

11. Has the alternate residential parent (ARP) ever served in the armed forces?  Yes  No If yes, which branch? _______________________

Dates of service: From: ________________________ To: ________________________________________________________________

Is the alternate residential parent (ARP) retired from the military or in the reserves?  Yes  No

12. Does the alternate residential parent (ARP) receive any pensions or benefits from the federal government (Social Security, SSI, VA, retired military,

etc.) or from other sources?  Yes  No

If yes, provide: Source (1): __________________________________________ Approximate monthly income amount _______________

Source (2): __________________________________________ Approximate monthly income amount ________________

Source (3): __________________________________________ Approximate monthly income amount ________________

13. Describe any assets the alternate residential parent (ARP) may own.

Cars, trucks, motorcycles

Make:

Model:

Year:

Color:

License plate number:

State:

Bank accounts:

Real estate:

Other assets:

14. Other contacts for the alternate residential parent (ARP). Give any information you have, even if it is incomplete:

Mother (first/middle/last name )

Maiden Name

Phone number:

Address/City/State

Zip

Father (first/middle/last name)

Phone number:

Address/City/State

Zip

Friend or other relative (first/middle/last name)

Phone number:

Address/City/State

Zip

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IV. COURT ORDER INFORMATION

Is there a court order for child support for the child(ren) for whom child support services are requested?  Yes  No

If yes, provide any information you have about the existing court order(s). Attach copies of the orders and payment records, if available.

Name of the court that issued the order

Date of the order

Docket/case number

County/State

How are payments made? (through court, IV-D agency, or directly to caretaker)

Amount of support ordered

Pay frequency ordered (weekly, monthly, other, etc.)

Payment due date

Date and amount of the last payment/collection

Amount of the arrearage

V. Use the area below to provide any additional information about your case that you think the child support office may need, including the

names of any other possible fathers of the child(ren) for whom you are applying. (Add a separate sheet if needed)

VI. INFORMATION ABOUT THE CHILD(REN)’S MEDICAL SUPPORT

Which parent provides medical insurance for the child(ren)? Mother __________ Father __________ Both _________ Neither __________

Carrier name: ___________________________________________________________________________________________

Policy number: ____________________________________________ Insured’s name: _____________________________________________

Monthly insurance premium: _________________________________ Number of family members covered by policy: _____________________

Name(s) of the child(ren) who are covered by this policy

_________________________________________________________ ______________________________________________________

Do the child(ren) have any unpaid medical bills?

Yes __

No __

(If yes, provide itemized detail and copies of all bills.)

Have you presented the unpaid medical bills to the insurance company?

Yes __

No __

(If yes, provide a copy of the Explanation of Benefits

from the insurance company.)

the insurance company.)

Have you presented the unpaid medical bills to the other party?

Yes __

No __

(If no, provide the other party a copy of the unpaid bills

now.)

Do the child(ren) have any recurring medical expenses not covered by

health insurance?

Yes __

No __

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VII. INFORMATION ABOUT THE CHILD(REN)

List below each of the children of the other parent shown on this application for which you are requesting child support services. For each

child, provide all of the necessary information and a copy of that child’s birth certificate. Attach additional sheets if needed.

1. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

2. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

3. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

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INFORMATION ABOUT THE CHILDREN (continued)

4. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

6. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

5. Child's Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth?  Yes  No

b. Was the mother married to another person at the time of birth?  Yes  No

c. If this child was born out of wedlock, has paternity been established?  Yes  No

d. If yes, was paternity established by:

 voluntary acknowledgment,  court order,  other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy?  Yes  No

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APPLICATION

I, ____________________________, am applying for Child Support services provided by the Child Support Agency of the Tennessee Department of Human

Services. I understand and acknowledge the following by initialing each line below:

____ The Child Support attorney handling my case represents the State of Tennessee, not me personally.

____ The information that I supply is the source for any petition filed for me.

____ The Child Support office will act to enforce the alternate residential parent (ARP)’s legal child support obligations. If the Child Support office determines any

action to be improper or unwarranted, it will not take that action.

____ If I give any information or testimony that a court finds to be false, the State may prosecute me for perjury.

____ If I get any money as the result of fraud on my part, I understand that the State may charge me with fraud. Also, the State may require me to pay back any

money that I get through fraud.

____ The Child Support office does not promise the success of any action, or results within a given time.

____ The services provided by the Child Support agency only include enforcing rights to child support, obtaining and enforcing health insurance orders,

establishing paternity, and in some limited cases, obtaining spousal support. These services do not include actions involving custody, visitation, or similar

issues. If such issues are raised in this case, I understand that I must secure other representation.

____ Since anyone in the State may apply for Child Support services, this means the Child Support office may provide services to others whose interests conflict

with mine.

____ I must pay filing fees or court costs if the court determines I am able to pay them. In addition, if I have never received Families First /

Temporary Assistance to Needy Families (TANF) benefits, the State will charge me a $25 annual fee for providing child support services, but only after

collecting at least $500 for my case in an annual period. To pay this fee, the State will keep the next $25 in child support that it collects for my case after the

initial $500. If my case requires action by another state, I must also pay any filing fees or associated costs the other state requires for my case to proceed.

____ If I have received TANF or Families First benefits in the past, any support collected each month above the current support owed each month will be kept by

the State to repay the TANF/Families First benefits I have received.

____ If the child(ren) in this case receive Medicaid, I must tell the Child Support office immediately

____ If I get a private attorney to represent me in obtaining child support, I agree to tell the Child Support agency immediately.

____ My case will be submitted to the IRS Treasury Offset Program if it meets the following conditions:

A. A court or administrative agency has ordered the alternate residential parent (ARP) to pay support.

B. A copy of the order, and any changes to the order, are on file in the Child Support office. Also, there must be a copy of the court's payment record on

file in the Child Support office. If there is no court payment record, I must give the Child Support office a signed affidavit of the amount owed by the

alternate residential parent (ARP).

C. The alternate residential parent (ARP) must owe at least $500.00 past due child support under such order.

D. The Child Support office has the Social Security number (SSN) of the alternate residential parent (ARP).

____ I further understand that if my case is submitted for the IRS Treasury Offset Program:

A. There is no guarantee that money will be collected on my behalf. A Treasury Offset Program collection through the Federal Tax Refund Offset Program

is only possible if the alternate residential parent (ARP) files a tax return and is due a refund from the IRS.

B. If money is collected through this process and a joint return is involved, the State has the right to hold the refund for six months before sending any

collections to me.

C. If I have received TANF or Families First benefits, the State will keep part or all of the refund to repay any TANF/Families First benefits previously

provided by the State.

D. The State has the right to withhold amounts from future IRS offsets if I do not voluntarily repay amounts paid to me in error.

E. The IRS charges a fee up to $25.00 for each collection made through the offset program. This fee will be deducted before I receive any collection.

____ I must repay to the State any money that I am overpaid, or that is sent to me in error.

A. I am personally liable for the return of any amounts I receive in error to correct an overpayment owed to the State for any reason to correct my child

support account, including but not limited to payments sent to me in error.

B. By checking the consent box at the end of this paragraph I am indicating consent to automatic withholding, without further notice, from any future

support payments collected on my behalf of amounts paid to me in error until the balance is paid in full. My consent is optional. The services I

receive will not be affected by the choice I make. If I give consent and later change my mind, I must notify the Child Support office in writing that

I wish to withdraw my consent. If I do not give consent to withholding by checking the “do not consent” box, the State is not prevented from

seeking to correct an error using all legal remedies available to them of which I will be responsible for payment of any costs of such action,

including court costs and attorney fees. (If neither of the following boxes is checked, it will be presumed that I have provided my consent.)

 I consent to such withholding.  I do NOT consent to such withholding.

I swear or affirm that the information I have provided in support of this application is correct to the best of my knowledge, information, and belief. I will cooperate

with the Department of Human Services and the local Child Support office in the matter. Further, I swear or affirm that I have read this affirmation and

acknowledgment. I declare that I understand it fully and agree with the terms.

___________________________________________________________ ____________________________________________

Signature Date

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Fillable Formcir Petition To ModifyCS Pkt (Metropolitan Government of Nashville & Davidson County, Tennessee)

Fill Online, Printable, Fillable, Blank Formcir Petition To ModifyCS Pkt (Metropolitan Government of Nashville & Davidson County, Tennessee) Form

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