Fillable Smtcsa Application Revised 11 1-18

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Smtcsa Application Revised 11 1-18

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Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
APPLICATION
Information provided on this form (including any attachments) may be shared with others for the sole
purpose of administration of the Tribal Child Support Agency and other related programs.
Filling out this form:
• Please fill out this form the best you can.
• The more information you can provide on this form the better job the case worker can do to assist
you.
• If you don’t know or are unsure of some of the information, you may leave that part blank.
•
If you have any questions about this form please talk with your Child Support Worker.
Name of Parent applying for services: _______________________________________________________
Relationship to child(ren): ___Mother ___Father ___Caregivers ___Relatives ___Agency
Services Requested: Federal regulations require the Tribal Child Support Agency to provide all services
appropriate for your case based on your circumstances. You may also choose “Only Locate Parent Services.”
___Establish Paternity ___Establish Child Support Order ___Enforce (Collect) Child Support
___Establish Medical Support Order ___Locate Absent Parent
Are you applying for services for an unborn child? ___Yes ___No If yes, due date ______________
IMPORTANT
If a child is conceived or born during a marriage, the husband is the legal father. If you believe that someone other than the
husband may be the biological father, provide the information about that person below. (The information given on the rest
of this form should be information about the husband and wife of the marriage not this person.)
Name: ________________________________________ Date of Birth: _______________________________
Social Security Number: ________________________ Address: ____________________________________
City: ________________________ State: ___________ Zip: ___________________
IMPORTANT
IS THERE AN ACTIVE COURT ORDERED RESTRAINING ORDER IN PLACE? __YES ____NO
If yes, who is the Restraining Order against? _________________
County Restraining Order Entered? ___________________________________________
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
SECTION I-Information about YOU, the parent applying for services
Legal Name: Last, First, Middle
Maiden/Alias Name:
Social Security Number:
Sex: ___ Male
___ Female
Race:
If Native American, what
tribe?
Tribal ID #
Home Address (City, State, Zip Code):
Mailing Address (if different from home address):
Home Phone:
Cell Phone:
Work Phone:
E-mail Address:
Employer’s Name:
Employer’s Phone Number:
Employer’s Address (County, City, State, Zip Code):
Income: _____ Hour
_____ Month
$_____________________ _____ Year
Please Check Services you are Receiving or Have Received:
_____ Child Support Services _____ Child Care _____W-2
_____ Medical Assistance _____ Food Share _____ TANF
Page 2
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
Member of the Armed Forces? ___ Yes ___ No If yes, ___ Active ___ Retired
Branch _______________________
Dates: From ______________ To ___________________ Veterans Benefits? ___ Yes ___ No
SECTION II-Information about the OTHER PARENT (Please see the note marked “important” on the
bottom of Page 1.
Legal Name: Last, First, Middle
Maiden/Alias Name:
Date of Birth:
Social Security Number:
Sex: ___Male
___ Female
Race:
If Native American, what Tribe:
Tribal ID#
Home Address (City, State, Zip Code):
Mailing Address (if different form home address):
Home Phone:
Cell Phone:
Work Phone:
E-mail Address:
Employer’s Name:
Employer’s Phone Number:
Employer’s Address (County, City, State, Zip Code):
Income ___ Hour
___ Month
$_______________ ___ Year
Page 3
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
How often are they paid?
___ Weekly ___ Every 2 Weeks ___ Monthly ___ Other
Health Insurance Available? ___ Yes ___ No
Premium $___________ Per ___ Week ___ Month
Are the Children Covered? ___ Yes ___ No
Member of the Armed Forces? ___ Yes ___ No If yes, ___ Active ___ Retired
Branch: __________________ Dates: From __________ To _____________
Veterans Benefits? ___ Yes ___ No
If the location of this parent is NOT known: Please provide the information below and any other
information you believe may help to find the person. Include all addresses where relatives may live and
type of income assets this parent may have. Include any additional information on page 6. Please include
a picture of the parent if available.
Distinguishing Marks (tattoos/ scars/ birthmarks)
Height
Weight
Hair Color
Eye Color
Race
Has this parent ever been arrested or convicted of a crime? ___ Yes ___ No
If yes, date of conviction? ____________ City of conviction? _______________
State of conviction? _________________
Name of this Parent’s Mother:
Name of this Parent’s Father:
Page 4
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
SECTION III-
Information about the children you are requesting services for. (These children must have the
same MOTHER AND FATHER, and these parents must be listed on this form in Sections I and II).
Name of First Child
Gender
Date of Birth:
City of Birth:
Father’s name on the Birth Certificate?
___ Yes ___ No ___ Unknown
County of Birth:
Name of High School:
Address:
City:
State:
Zip Code:
Where does the child live most of the time?
___ Mother ___ Father ___ Both Equally ___ Not yet decided by court
Name of the Second Child
Gender
Social Security Number:
Date of Birth:
City of Birth:
Father’s name on the Birth Certificate?
___ Yes ___ No ___ Unknown
County of Birth:
Name of High School:
Address:
Page 5
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
City:
State:
Zip Code:
Where does the child live most of the time?
___ Mother ___ Father ___ Both Equally ___ Not yet decided by court
Name of Third Child
Gender
Social Security Number:
Date of Birth:
City of Birth:
Father’s name on the Birth Certificate?
___ Yes ___ No ___ Unknown
County of Birth:
Name of High School:
Address:
City:
State:
Zip Code:
Where does the child live most of the time?
___ Mother ___ Father ___ Both Equally ___ Not yet decided by court
Please include any additional information here:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Page 6
Stockbridge-Munsee Community
Tribal Child Support Agency
P.O. Box 70, N8402 Moh He Con Nuck Road
Bowler, WI 54416
Telephone: (715)793-4036 ● Fax: (715)793-4039
Revised 11/01/2018 LV
TAX INTERCEPT INFORMATION: I understand that the Stockbridge-Munsee Child Support
Department will submit any certifiable past-due child support debts to the State of Wisconsin tax/lottery
intercept programs. I understand that I am applying for State IV-D services for purposes of submitting
arrearages for Federal tax refund intercept programs. I understand that if I receive the other parent’s
intercepted tax refund money that is later recalled by the Federal Internal Revenue Service (IRS) or the
State Department of Revenue (DOR), I must immediately return the money. If I cannot pay all the
money at once, I will follow a payment plan until the amount is repaid in full. (If the tax refund is
recalled, you will receive a letter with information about how to return the money and how to set up a
payment plan.
CHILD SUPPORT ORDERS: I understand that the law does not permit percentage orders in child
support agency cases. If I am opening a new child support case or reopening a closed child support case
with the child support agency and have a percentage order, I understand that the child support agency is
not responsible for reconciling the order. The child support agency is required to change the percentage
order into a dollar amount order. By submitting this application, I am agreeing to cooperate with the
agency in changing the order. Disclaimer: Stockbridge-Munsee Community will bring any necessary
administrative or court actions to establish paternity (legal fatherhood) or to establish or enforce a
support order. However, the child support attorney does not represent either parent, but rather
represents the Tribe’s interest in enforcing support.
Overpayments: I understand and agree all overpayments will be recouped.
I hereby request child support services under the Child Support Enforcement Program under Title IV-D
of the Social Security Act. I understand that I must cooperate with the Child Support Agency by
providing information that affects my case and by keeping my appointments with the agency.
Upon oath, I certify that to the best of my knowledge, the above information is true and correct.
Dated this _____________ day of _______________________, 20__
___________________________________________
Signature of Applicant
Page 7
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Smtcsa Application Revised 11 1-18

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Completed 27 January 2021

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