Fillable Michigan office of child support CHILD SUPPORT SERVICES APPLICATION/REFERRAL

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Michigan office of child support CHILD SUPPORT SERVICES APPLICATION/REFERRAL

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DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word
1
IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL
FOR OFFICE USE ONLY
Michigan Department of Health and Human Services
Date Requested Date Provided Date Filed Program
748
Provided
Office of Child Support (OCS)
Please check your relationship to the children for whom you are applying for child support
services:
IV-D Case No. MDHHS Case No. County District Unit Worker
Custodial Parent
Non-Custodial Parent or Alleged Father
Other Caretaker, Specify
• Custodial Parent - Complete all sections of the form, enter information about you in Section A.
• Non-Custodial Parent or Alleged Father – Complete all sections of the form except Section F, enter information about you in Section B.
• Other Caretaker - Complete all sections of the form, enter information about you in Section A. Complete information about each parent who is not in the home in Section B.
(Please complete a separate application for each parent who is not in the home.)
A. INFORMATION ABOUT THE CUSTODIAL PARENT/CARETAKER OF THE CHILD
1. Name (First, Middle, Last, Suffix)
Maiden Name (If applicable)
2. Birthdate
3. Social Security No.
4. Home Address (P.O. Box No., No. and Street) City State Zip Code County
5. Home Phone No. 6. Work Phone No. 7. Cell Phone No.
( )
( )
( )
B. INFORMATION ABOUT THE PARENT WHO IS NOT IN THE HOME
8. Parent’s Name (First, Middle, Last, Suffix) Maiden Name (If applicable) 9. Social Security No. 10. Birthdate 11. Age 12. Sex (M or F)
13. Home Address (P.O. Box No., No. and Street) Current Last Known City State Zip Code 14. Home Phone No. 15. Cell Phone No.
( )
( )
16. Weight 17. Height 18. Hair Color 19. Eye Color
20. Birthplace (City, State) 21. Driver’s License Number
22. Car (Make, Model and Year)
23. License Plate Number
24. Race or Ethnic Code: 25. Any Visual Marks or Scars?
Alaskan Native
Hispanic
White
American Indian Multiracial – More than one racial-ethnic group Middle Eastern
Asian or Pacific Islander Black, not of Hispanic origin Other
26. First Employer Name Current Last Known 27. Employer Address (P.O. Box No., No. and Street) City State Zip Code 28. Phone No.
( )
29. Second Employer Name Current Last Known 30. Employer Address (P.O. Box No., No. and Street) City State Zip Code 31. Phone No.
( )
C. MARITAL STATUS INFORMATION
32a. Has the mother ever married? b. Name of Spouse c. Date Married d. Place (City, County, State)
No Yes, If Yes>>
33a. Is the mother
b. Date c. Court Order Exist? d. Court Order No. e. Where (City, County, State)
Separated
Legally Separated >>
No Yes, If Yes>>
34a. Is the mother b. Date c. Court Order Exist? d. Court Order No. e. Where (City, County, State)
Divorced
Divorce filed >>
No Yes, If Yes>>
Please attach a copy of all court orders pertaining to the family members listed on this application, including Personal Protection Orders and guardianship papers.
DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word
2
D. INFORMATION ABOUT CHILD(REN)
Child One (Please include separate pages if more than three children)
35a. Child’s Full Name (First, Middle, Last, Suffix)
b. Birthdate
c. Social Security Number
d. Sex (M or F)
e. City, County & State of Birth
f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?
g. When and where did the mother become pregnant?
Date
City
County
State
h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No
If yes, provide the following information about that document:
Date
City
County
State
CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)
36a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type d. Policy or Group No.
PPO PPOM Traditional
Child Two
37a. Child’s Full Name (First, Middle, Last, Suffix)
b. Birthdate
c. Social Security Number
d. Sex (M or F)
e. City, County & State of Birth
f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?
g. When and where did the mother become pregnant?
Date
City
County
State
h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No
If yes, provide the following information about that document:
Date
City
County
State
CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)
38a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type d. Policy or Group No.
PPO PPOM Traditional
Child Three
39a. Child’s Full Name (First, Middle, Last, Suffix)
b. Birthdate
c. Social Security Number
d. Sex (M or F)
e. City, County & State of Birth
f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?
g. When and where did the mother become pregnant?
Date
City
County
State
h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No
If yes, provide the following information about that document:
Date
City
County
State
CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)
40a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type
d. Policy or Group No.
PPO PPOM Traditional
DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word
3
E. GENERAL INFORMATION
41. I believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or the child. Yes No
42. I have received or I am currently receiving benefits from the Family Independence Program (FIP) or I have received past benefits from Aid to Dependent Children (ADC).
Yes No
If yes, when?
Where?
43. I have received or I am currently receiving Medicaid (MA). Yes No
If yes, when?
Where?
44. I am currently receiving: Food Assistance Program (FAP) Yes No Child Development and Care (CDC) Yes No
F. ACKNOWLEDGEMENT FOR CUSTODIAL PARENTS AND CARETAKERS
The Michigan Office of Child Support (OCS) processes child support payments through the Michigan State Disbursement Unit (MiSDU), which is part of the Michigan Department of Health and Human Services
(MDHHS). The MiSDU receipts and distributes payments by direct deposit to a bank account, to a debit card, or by paper check.
If I am sent money in error or overpaid, the MiSDU will take all the necessary steps to correct errors in the processing of my child support payments. By checking the “yes” box below, I give OCS permission to
withhold an incremental amount specified below from future child support payments owed to me. To revoke my consent, I must notify the Friend of the Court office. Failure to check “yes” has no effect on my
eligibility for IV-D Child Support services through OCS.
Yes, (circle one) 10% 25% or 50% Failure to choose a percentage will result in a default amount of 25%.
No, please contact me before you attempt to recover an amount from my support payments.
G. ACKNOWLEDGEMENT FOR ALL APPLICANTS
I request child support services available under Title IV-D of the Social Security Act.
All Services
Locate Only (for custodial parents and caretakers only)
Medical Support Only (for Medicaid cases only)
I understand that disclosure of my Social Security number is mandated by the Social Security Act, 42 USC 666(a)(13), in order that
Michigan’s child support program may provide services related to the establishment of paternity and the establishment, modification
and enforcement of child support obligations. I understand that I must cooperate in taking support action to ensure that my child
support case remains open. I declare that the information provided above is true and correct to the best of my knowledge and agree
to report changes in my circumstances that may affect support action in my case.
I certify that I have received a copy of DHS Publication 748, “Understanding Child Support, A Handbook for Parents.”
Authorities:
45 CFR 302.33 Completion: Application is voluntary for non-
assistance applicants.
R 400.3009 MAC and R 400.5008 MAC Failure to complete may result in
loss of benefits from Child Development and Care (CDC) and the Food
Assistance Program (FAP). Current FAP and CDC recipients are not
required to sign the form.
42 USC 654(29) Failure to provide information may result in loss of
Family Independence Program (FIP) benefits for all family members and
loss of Medicaid (MA) for all adult members.
Applicant’s Signature (Signature is Required)
Date
Return completed application to:
Michigan Office of Child Support
Central Functions Unit
P.O. Box 30744
Lansing, MI 48909
Applicant’s Printed Name
Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race,
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political
beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
make your needs known to an MDHHS office in your area.
This institution is an equal opportunity provider.
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Michigan office of child support CHILD SUPPORT SERVICES APPLICATIONREFERRAL

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Completed 20 December 2019

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