Fillable Muscogee (Creek) Nation Office of Child Support Enforcement

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Muscogee (Creek) Nation Office of Child Support Enforcement

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Revised 05/2019
1
Muscogee (Creek) Nation
Office of Child Support Enforcement
APPLICANT INFORMATION – Please keep for your records
Who may apply or is eligible?
You are eligible to apply for Child Support Enforcement (CSE) services if:
You or the children are members or eligible for membership in the Muscogee (Creek)
Nation.
The children are citizens or members of a federally recognized Indian Tribe or are
eligible for citizenship or membership of a federally recognized Indian Tribe and are
residing within the territorial boundaries of the Muscogee Creek Nation.
MCN Office of Child Support Enforcement (CSE) can help:
Locate the parent of a child or the assets of the parent
Establish paternity for a child
Obtain a child support order
Collect child support payments
Review child support orders for possible modifications
Keep us informed about you, your children, and the other parent’s:
Current address and phone number
Current work address and phone number
NOTE: The post office does not forward child support documents or payments. You
must inform CSE of any change in your address to ensure you receive
correspondence or legal documents. We must be able to get the necessary
information to you to work your child support case.
Other Information:
Send CSE copies of any orders
Establishing paternity
Granting a divorce
Granting custody
Setting child support
Awarding guardianship
Granting custody or setting support in a juvenile court case
Please know:
CSE will decide how to collect your child support.
CSE staff represents only the Muscogee (Creek) Nation.
Information you give CSE may be shared as required by law if needed to establish or
enforce an order.
CSE uses the address of record you provide as your public mailing address. Legal
and other official papers will be sent to you by regular mail at this address.
If family violence is an issue, please give an address of record different from your
home address.
Print Form
Reset Form
Revised 05/2019
2
You must provide your social security number.
All payments must be made through the Muscogee (Creek) Nation Office of Child
Support Enforcement.
CSE can sign and negotiate payments related to child support.
Payments must be made in the form of a cashier’s check or money order.
CSE distributes child support as required by federal and tribal law. Current support is
applied to the month in which it is received by CSE.
Some parents pay child support for children in more than one household. Payments
are divided so that each household receives a share.
If the custodial parent received Tribal TANF, TANF, or AFDC, the noncustodial
parent’s federal tax refund may be taken to repay that debt. Once state debt is repaid,
those collections are sent to the family for past due support.
If a custodial parent is overpaid child support, the custodial parent will be required to
pay it back.
CHILD SUPPORT PAYMENTS: If our office is able to enforce a child support
order, your child support will be issued in the form of a debit card or direct
deposit. If you wish to enroll in direct deposit, please complete the Affidavit of
Direct Payments and return with this application. Otherwise, you will
automatically be enrolled in the debit card program
You must:
Provide CSE with all requested information in a timely manner
Inform CSE when your address of Address of Record changes
Inform CSE if a child’s address changes
Inform CSE of all child support payments you receive from anyone other than CSE
Inform CSE if you ask another person or agency to collect child support for you
Inform CSE of any new information that relates to collecting child support
Your child support payments must be sent to:
Muscogee (Creek) Nation
Office of Child Support Enforcement
P.O. Box 100
Okmulgee, OK 74447
CSE contact information:
Phone number: (918) 295-0800
Fax number: (918) 295-0880
Toll Free: 1-800-482-1979
www.mcnchildsupport.com
Please keep these pages for your records
Revised 05/2019
3
REMINDERS
1) Did you read, sign, and notarize the following documents as needed:
□ Application
□ Statement of Understanding
□ Affidavit of Direct Payments
□ Statement of Understanding
□ Authorization for Release of Information
□ Affidavit to Withdraw from IV-D Services
2) Did you attach copies of the following documents as needed:
□ State issued birth certificates for all children (Hospital issued birth
certificates with baby footprints will not be accepted)
□ Copies of CDIB or tribal citizenship cards for all children
□ Copies of Social Security cards for all parties in the case
□ Copy of custodial parent’s driver’s license or photo identification
□ Copies of court orders, divorce decrees, & paternity affidavits
(State Form 209)
□ List an address of record different from your home address if you or
your children are at risk for family violence
Send original application to:
Muscogee (Creek) Nation
Department of Justice
Office of Child Support Enforcement
P.O. Box 100
Okmulgee, OK 74447
To visit our office:
Muscogee (Creek) Nation Office of Child Support Enforcement
MCN Housing Building
2951 N. Wood Drive, Ste. 245
Okmulgee, OK 74447
OR
Robert S. Kerr Building
440 S. Houston, Ste. 402
Tulsa, Oklahoma 74127
Revised 05/2019
4
OFFICE USE ONLY
Date Requested: ______________ Date Sent: ______________ MCNFGN: ______________
Date Received: _______________ FGN: ___________________
Request Type: □ Phone □ Walk-in □ Mail □ Website / Internet
1. PERSON APPLYING FOR CHILD SUPPORT SERVICES: Please mark all that apply
□ I am the custodial parent/guardian. I am requesting services for the child(ren) living with me.
I seek child support from:
□ The child(ren)’s mother, _____________________________ (mother’s name)
□ The child(ren)’s father, ______________________________ (father’s name)
□ I am the non-custodial parent. I am requesting services for the child(ren) living
with the custodial parent listed in section 3.
□ This is my first application with the Muscogee (Creek) Nation Child Support Enforcement.
□ I am reopening my case with the Muscogee (Creek) Nation
2. FAMILY VIOLENCE:
Do you believe that you or your child(ren) may be at risk of emotional or
physical harm if the other parent knows where to find you?
□ yes □ no
Do you have, or have you ever had, a protective order against you or the non-
custodial parent?
□ yes □ no
If yes, what court issued the order?
Date:
I, _______________________________, state that:
Print your name
□ Family violence IS a risk to me or my child(ren) from:___________________________
Name of potentially dangerous person
□ Family violence IS NOT an issue in my case.
The address you give on this application will be your address of record. An address of record
is the address where you get legal and other official documents by regular mail. This
address is available to the public in legal documents. If family violence is an issue,
your address of record should be different from a home address.
□ Please use the following address as my address of record:
Street or P.O. Box
City
State
Zip
3. REFERRAL SECTION: How were you referred to MCN CSE?
□ State Office □ MCN TANF □ MCN Child Care □ Other:_____________
Muscogee (Creek) Nation
Office of Child Support Services (CSE)
Child Support Application
Revised 05/2019
5
4. CUSTODIAL PARENT: This section is about the parent/guardian with whom the child(ren)
reside.
Legal Last Name: First Middle
Maiden/alias name
Date of Birth:
Social Security Number:
Gender: □ Male □ Female
Race:
If Native American, what tribe?
What is the relationship of the child(ren) to the custodial
parent?
Who has legal custody?
Mailing Address: City State Zip Code
Physical Address: City State Zip Code
Phone Number: Alternate Phone Number:
Email Address:
Employer’s Name:
Employer’s Phone Number:
Employer’s Address: City State Zip Code
Income: Check box and complete. Please attach a copy of check stub.
□ $____________/Hour □ $_____________/Month
Are benefits, such as TANF or SoonerCare
(Medicaid), being provided?
□ yes □ no
What tribe/state is providing the benefits?
Do you have a private attorney currently working
on this case?
□ yes □ no
Attorney name, address, and phone:
COMMENTS:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
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5. NON-CUSTODIAL PARENT: This section is about the parent who does not have custody of
the child(ren).
Legal Last Name: First Middle
Alias names:
Date of Birth: Place of Birth (city, state): Social Security Number:
Relationship to child(ren):
Gender: □ Male □ Female
Race:
If Native American, what tribe?
Height: Weight:
Eye Color:
Hair Color:
Identifying Marks (tattoos, scars, etc.):
Home Address: City State Zip
Phone Number:
Alternate Phone Number:
Employer’s Name:
Employer’s Phone Number:
Employer’s Address: City State Zip
Income: (check box and complete)
□ $________________/Hour □ $__________________/Month
Is non-custodial parent currently incarcerated:
□ yes □ no
Name of Facility:
Is non-custodial parent on probation or parole?
□ yes □ no
Name of officer, city, state
Is non-custodial parent retired?
□ yes □ no
From where?
Is non-custodial parent disabled?
□ yes □ no
If receiving benefits, what type?
Is non-custodial parent currently married?
□ yes □ no
If yes, to whom?
Is non-custodial parent enlisted in the military?
□ yes □ no
What branch?
Please state any additional information regarding the non-custodial parent which may be
helpful: ____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Revised 05/2019
7
6. INFORMATION ABOUT THE CHILD(REN): This section concerns the child(ren). Complete a
separate Section 6 for each child belonging to the same mother and father. A child(ren) of a
different set of parents requires a separate application.
Legal Last Name of Child: First Middle
Social Security Number:
Date of Birth:
City of Birth:
State of Birth:
Gender:
□ Male □ Female
Race:
If Native American, what
tribe?
Has CDIB been issued?
□ yes □ no
Does the child live with you?
□ yes □ no
If no, explain
Does the child attend school?
□ yes □ no
School attending
Grade
Estimated graduation
date
What is the relationship between the mother and father of the
child(ren)?
□ Never Married □ Married / Living Apart □ Divorced
Date of Separation:
Date of Marriage, if applicable:
City:
County:
State:
Legal Status:
□ Paternity needs to be established legally – Complete the Paternity Questionnaire
□ Parents married, living apart, no support ordered – Complete the Paternity Questionnaire
□ Paternity established, no support ordered – Skip to Section 7
□ Support has been ordered for this child – Skip to Section 7
PATERNITY QUESTIONNAIRE:
Information about the mother of the child:
Legal Last Name First Middle
Date of Birth
Currently Pregnant?
□ yes □ no
If yes, who is the biological
parent?
When is the baby due?
Was the child conceived in the
State of Oklahoma?
□ yes □ no
If no, what state?
Has an acknowledgment of
paternity form been signed?
□ yes □ no
If yes, date completed:
What state?
Has the acknowledgment been
withdrawn?
□ yes □ no
If yes, date withdrawn?
Revised 05/2019
8
Has genetic testing to
determine paternity been
conducted
□ yes □ no
If yes, please explain:
Information about the mother’s relationship with the alleged biological father:
Has the alleged biological father ever paid any bills for this child?
□ yes □ no
(If yes, attach a list of dates and amounts. Keep the receipts, if any.)
Did the mother have a sexual relationship with anyone other than the alleged biological father
within 90 days before or after the date the mother became pregnant with this child?
□ yes □ no
Last name of this person
First
Middle
Phone Number:
Mailing Address
City
State
Zip Code
Has any other person been
named the father of this child?
□ yes □ no
If yes, person’s full name:
Information about the mother’s husband when the child was born: Please complete this
section if the mother was married at the time of this child’s conception or birth and the
husband is NOT the father of the child.
Legal Last Name
First
Middle
Other names used
Address: □ present or □ last known
Phone Number
Street Address
City
State
Zip Code
Date of Birth
Birthplace
Social Security Number
Race
Height
Weight
Hair Color
Eye Color
Identifying Marks, such as scars or tattoos
Current Employer’s Name
Employer’s Address
Employer’s Phone Number
What is the current relationship between the husband and the mother of the child?
□ Married □ Divorced – Date of Divorce: ________________ □ Married / Separated
If Married, type of marriage: □ Common-Law □ Licensed
Has a court order stated the husband is not the father? □ yes □ no
Attach a copy of all orders
Revised 05/2019
9
7. ADDITIONAL INFORMATION
Please check if you have ever appeared in any court for one of the following reasons?
□ Child Support □ Divorce □ Child Custody □ Legal Paternity □ Domestic Violence
If yes, where did you appear (city/county and state): _____________________________
COURT ORDER INFORMATION: Provide a complete copy of any court order, such as a
divorce decree, paternity order, custody order, or tribal order. Attach a copy to this form.
Date of order:
Court Case
Number:
Where was the court order issued?
If tribal court, what tribe?
City:
County:
State:
Zip Code:
Was child support ordered?
□ yes □ no
If yes, how much?
Per week, bi-weekly, or
per month?
Was a private attorney consulted for
this order?
□ yes □ no
Name of attorney and phone number:
PENDING COURT ORDERS:
Is there any legal actions pending that affect the child(ren)? □ yes □ no
Check all that apply: □ Visitation □ Custody □ Other:
If yes, provide a copy and fill in the blanks below.
Date of Filing:
Case Number
County
State
Is the child(ren) in Indian Child Welfare (ICW) or Child Welfare custody? □ yes □ no
Date child(ren) placed in ICW/CW custody:
If child in ICW care, what tribe?
Date of filing:
Court Case Number:
County:
State:
What court is the paperwork filed at?
If tribal court, what tribe?
MODIFICATION OF CHILD SUPPORT:
Date of Modification:
Court Case Number:
Court order was granted in (state/tribe):
City:
County:
State:
Revised 05/2019
10
HEALTH INSURANCE COVERAGE:
Is the child(ren) enrolled in a health insurance plan? □ yes □ no
Who is the provider of health insurance?
□ Father □ Mother □ Other person:
List Children Enrolled:
Cost per month to cover only the child(ren)?
$
Effective date:
Name of Insurance Company:
Address:
City
State
Zip Code
Health Insurance Group Number
Policy Number
Area Code & Phone Number
Does your child(ren) have an established file at any Muscogee (Creek) Nation Health Facility
or any other Indian Health Service (IHS) facility? □ yes □ no
CHILD CARE EXPENSES:
What amount do you pay for child care for the child(ren) listed on this application?
$______________________ □ Weekly □ Biweekly □ Monthly
Revised 05/2019
11
STATEMENT OF CHILD SUPPORT PAYMENTS RECEIVED
Custodial Parent Name:
Non-custodial Parent Name:
Child’s Name:
Child’s Date of Birth:
Child’s Name:
Child’s Date of Birth:
Child’s Name:
Child’s Date of Birth:
Child’s Name:
Child’s Date of Birth:
□ I state that child support in the amount of $ _____/month is due from_________________.
□ I have (check one): □ received □ paid child support payments as shown below. (List all
child support payments below).
□ I have received no child support from the non-custodial parent.
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Month
Year:
Jan
$
Feb
$
Mar
$
Apr
$
May
$
June
$
July
$
Aug
$
Sept
$
Oct
$
Nov
$
Dec
$
Revised 05/2019
12
4. The following is an explanation regarding the period(s), if any, for which support may be
due but no request is being made to collect:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
I state under penalty of perjury under the laws of the Muscogee (Creek) Nation and State of
Oklahoma that the foregoing is true and correct.
Form must be signed in the presence of a notary public
________________________________________ ______________________
Applicant’s Signature Date
(NOTARY USE ONLY)
STATE OF: ___________________________
COUNTY OF: __________________________
I verify that the above named person signed this affidavit before me on this _________ day of
________________, 20_______.
Notary Public: ______________________________________
My Commission Expires: ____________________________
Commission Number: ____________________________
Revised 05/2019
13
AUTHORIZED AGREEMENT FOR AUTOMATIC CREDITS
(DIRECT DEPOSIT)
_______________________________________________________________
I (we) hereby authorize Muscogee (Creek) Nation Office of Child Support to initiate credit
entries to my (our) account indicated below and the financial institution named below,
hereinafter called FIRSTAR BANK, to CREDIT the same account. I (we) acknowledge that
the origination of ACH transactions to my (our) account must comply with the provisions of
U.S. law.
__________________________________________________________________________
PRIMARY ACCOUNT:
(Financial Institution Name) (Branch)
(Address)
____________________ ____________________ ___________________
(Primary Account Name) (Routing / Transit Number) (Account Number)
Type of Account:
This authority is to remain in full force and effect until Muscogee (Creek) Nation Office of
Child Support has received written notification from me (or either of us) of its termination in
such time and manner as to afford Muscogee (Creek) Nation Office of Child Support and
Firstar Bank a reasonable opportunity to act on it.
_____________________________ _____________________________
(Authorized Signature) (Authorized Signature)
_____________________________ _____________________________
(Printed Name) (Printed Name)
_____________________________ _____________________________
(Date) (Date)
PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM!
Checking
Savings
Revised 05/2019
14
STATEMENT OF UNDERSTANDING
**Signature and Notarization Required**
By signing this application, I authorize CSE to:
Take child support establishment and enforcement action CSE finds appropriate
Endorse and negotiate payments related to child support, including cashiers checks,
money orders, and electronic payments on my behalf and on behalf of the child(ren) in
my case, if I am the custodial parent.
1. I understand the Muscogee (Creek) Nation Office of Child Support Enforcement (CSE) is
here to act in the public interest of the child and to make sure that the parents financially
support their children. I understand that the responsibilities of the child support program do
not allow the staff of CSE to have the same confidential relationship with me as I would have
with a private attorney. Information I provide will be kept from the general public but may be
used as needed to collect support from either parent. I give CSE permission to give any
necessary information to law enforcement officers, public officials, court or others to assist
me to collect child support or medical support.
2. I understand that CSE ensures that all personal information provided to CSE such as
addresses, telephone numbers, employer names, etc. shall remain confidential. No personal
information will be shared between the custodial parent and non-custodial parent. However,
CSE may share information with other authorized state and tribal agencies.
3. I understand that CSE uses the address of record I provide as my public mailing address.
Legal and other official documents will be sent to me by regular mail at this address.
4. I should provide an address of record different from my home address if I believe I or my
child(ren) could be at serious risk of emotional or physical harm.
5. I understand that the post office does not forward child support payments to a new address
I have provided them. I must inform CSE of my new address in order to receive my child
support payments, and court and other legal documents.
6. I understand that CSE attorneys or the child support staff does not personally
represent me nor give any party legal advice. I have the option to hire an attorney at
my own expense. At the time of obtaining a private attorney, CSE will no longer correspond
with me directly; ONLY my attorney will contact the CSE attorney directly.
7. I agree to complete forms and affidavits as requested, to submit genetic testing, and attend
court to give testimony. I agree to cooperate fully with CSE, law enforcement officers, and
the court. I will notify CSE of my new address in writing every time I move.
8. I agree to give all identifying information requested to assist in locating and collecting child
support from the non-custodial parent (NCP) and/or prove who the biological father of my
child(ren) is. This includes any information that I know about or any documentation that I
have.
Revised 05/2019
15
9. I understand that CSE cannot help with issues such as custody and property
settlements. I agree to tell CSE if I hire a private attorney to collect or modify child
support or spousal support for me.
10. I agree CSE will decide the best way to collect child support.
11. I understand that CSE has an agreement with the State of Oklahoma to submit my case
for tax offset and other enforcement activities as needed to provide the full support for my
children. I further understand that the State of Oklahoma will open my case for limited
services only.
12. I understand that money collected from federal and state tax intercepts will first be applied
to monies owed to the tribe or state for funds expended on behalf of my children and myself.
I understand that tax intercepts may take refunds due to both the NCP and the current
spouse on joint returns. I understand that CSE or a state agency will hold the intercept for up
to six months. I further understand that I may receive tax collections that are actually owed to
the NCP’s current spouse and I agree that if the NCP’s current spouse files an Injured
Spouse claim for his/her portion of the tax refund collection, I will return that portion to the
Office of CSE.
13. I agree that starting with the date of my application, I give CSE the authority to endorse
child support checks made out to me. I understand that if I do not notify CSE of direct
payments or turn in child support paid directly to me, my case may be closed.
14. I understand that if I keep child support payments to which I am not entitled because the
NCP paid me directly for support assigned to the tribe or state or because payments were
sent to me in error, CSE will recover the overpayments from me. I understand CSE shall be
entitled to recover the overpayment by withholding amounts from my child support payments
and/or through interception of my federal and/or state tax refund.
15. I understand that it is law that CSE will collect money owed to the tribe or state for any
TANF/AFDC my children received in the past or are currently receiving. Any amount of
money collected that is more than what is due every month for current support will be paid to
the tribe or state for any TANF/AFDC paid to my children or me in the past.
16. I understand and agree to all the terms above. I understand that if I violate any of the
agreements or fail to cooperate with the Office of CSE, my case will be closed. The
information provided in this application is true and correct to the best of my knowledge.
17. I request any tribal, state, or federal IV-D agency to close their case as allowable under
Tribal, State, or Federal Law.
Revised 05/2019
16
I understand CSE cannot guarantee the following:
1) Identification and location of the biological father
2) Issuance of a child support order from the court
3) Enforcement of a child support order
4) Collection of child support money from the non-custodial parent
I have read and understand the Office of Child Support Enforcement (CSE) Services and
Responsibilities at the beginning of this application. Further, I state under penalty of perjury
that the foregoing is true and correct and that all of the information I have given, particularly
information that relates to all individuals who might be the father of the child(ren), is true and
correct. I acknowledge the truth of all information provided in all sections in this information
packet. I understand this acknowledgment applies to the information packet as a whole and
to each individual section.
Form must be signed in the presence of a notary public
Applicant’s signature: _______________________________ Date: __________________
(NOTARY USE ONLY)
STATE OF: ___________________________
COUNTY OF: __________________________
I verify that the above named person signed this affidavit before me on this _________ day of
________________, 20_______.
Notary Public: ______________________________________
My Commission Expires: ____________________________
Commission Number: ____________________________
Revised 05/2019
17
Muscogee (Creek) Nation
Office of Child Support Enforcement
AUTHORITY FOR RELEASE OF INFORMATION
To Whom It May Concern:
I hereby authorize any investigator bearing this release, or a copy thereof, to obtain any
information relating to my activities from schools, credit bureaus, residential management
agents, employers, criminal justice agencies or individuals. This information may include but
is not limited to: academic, residential, achievement, performance, attendance, personal
history, disciplinary, arrest or conviction records. I hereby direct you to release such
information upon request of the bearer. I understand that information released is for official
use and may be disclosed to such third parties as necessary in the fulfillment or official
responsibilities.
I hereby release any individual, including record custodians, from any and all liability for
damages of whatever kind and nature which may at anytime result to me on account of
compliance, or any attempts to comply with this authorization. Should there be any questions
as to the validity of this release, you may contact me as indicated below.
Date: ______/______/______
Signature (full name): ____________________________________________________
Full Name (print): ____________________________________________________
Aliases: ____________________________________________________
(Include any married names, nicknames, and/or maiden names)
*Social Security Number: ______-______-______
Date of Birth: ______-______-______
Current Address: ____________________________________________________
Address City State Zip
Telephone Number: (______) ______-_______
*The request of your Social Security Number is a means to uniquely identify your application records
within our tribal files. By providing an accurate Social Security Number and full name, you assure the
accomplishment of the application process.
Revised 05/2019
18
Muscogee (Creek) Nation
Office of Child Support Enforcement
Affidavit to Withdraw from IV-D Services
I, ______________________________________, would like my child support case to be worked by
Muscogee Creek Nation Office of Child Support Enforcement. I believe I have an open case with
one or more of the following child support programs:
□ State of Oklahoma
□ State of Kansas
□ State of Arkansas
□ Cherokee Nation
□ Chickasaw Nation
□ Modoc Tribe
□ Osage Nation
□ Kaw Nation
□ Kickapoo Tribe
□ Ponca Tribe
□ Comanche Nation
□ Delaware Tribe
□ Apache Tribe
□ Other:___________
Statement of Understanding:
I have read and understand the following: (Please initial the following)
_____ Enforcement action will be taken over by MCNCSE and I request my case to close with all
other CSE agencies.
_____ If state monies are owed on my case, the case may remain open with both agencies, but
enforcement action will only be taken by MCNCSE.
_____ I cannot waive any state monies that may be owed on my behalf.
Applicant’s signature: _______________________________ Date: __________________
(NOTARY USE ONLY)
STATE OF: ___________________________
COUNTY OF: __________________________
I verify that the above named person signed this affidavit before me on this _________ day of
________________, 20_______.
Notary Public: ______________________________________
My Commission Expires: ____________________________
Commission Number: ____________________________
After submitting your completed application, you must forward to CSE all child
support payments you receive from anyone other than CSE. Mail payments to:
Muscogee (Creek) Nation
Office of Child Support Enforcement
P.O. Box 100
Okmulgee, OK 74447
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Muscogee (Creek) Nation Office of Child Support Enforcement

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Completed 1 February 2022

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