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Tlingit and Haida Indian Tribes of Alaska Tlingit (Central Council Tlingit and Haida Indian Tribes of Alaska)

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U.S.A. forms for Central Council Tlingit and Haida Indian Tribes of Alaska

BROWSE CENTRAL COUNCIL TLINGIT AND HAIDA INDIAN TRIBES OF ALASKA (AK) FORMS

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TCSU Application for Services 2020 1
Please indicate which service you want. You must provide all information necessary for these services.
Attach complete copies of orders or documents relating to custody, support and paternity. DO NOT SEND
ORIGINALS. Incomplete applications may be returned.
Support Order Establishment Paternity Establishment (Complete Paternity Witness Affidavit)
Location Services Medical Support Order Establishment
Modification & Enforcement of an Existing Order Foster Care
Please answer each question as fully as possible (incomplete information may delay your application process). Print
or type all answers. Complete one form for each Corresponding Parent on behalf of the concerned child(ren). If you
do not know an answer, put “UNK” or if it not applicable put N/A in the space. If you need more space, use a separated
sheet and attach it to this from.
Check here if you are a victim of domestic violence and you want your address kept confidential from the other party. Please submit an
“Affidavit and Request for Address Confidentiality” in order to petition your address confidential. TCSU will respond in writing with a decision.
You Are the: Custodial Parent Non-Custodial Parent
Third Party - fill out applications for each parent Mother Father
Information about You:
Name (Last, First, Middle)
Previous Names
SSN
Date of Birth
Mailing Address
City
State/Zip
Sex
M F
Physical Address
City
State/Zip
Telephone (Home)
(Message or Cell)
Email Address
Enrolled Member or eligible to be enrolled with CCTHITA? Yes No If no, enrolled with what tribe: ___________________
Are the children enrolled or eligible to be enrolled with CCTHITA? Yes No If no, enrolled with another tribe: _________________
Are you currently receiving TANF/Cash Assistance? Yes No If yes, Where? __________________________________________
Have you ever received TANF/Cash Assistance? Yes No If yes, When? ______________________________________________
Where?______________________________________________
Does an attorney represent you in any matters related to the child or the parents? Yes No If yes, provide attorney’s name address,
and phone: _______________________________________________________________________________________________
Your Driver’s License Issued State _________________________and License # _______________________________
Are you currently employed? Yes No If yes, Where? ________________________________ Employer Phone#_______________
CENTRAL COUNCIL
Tlingit and Haida Indian Tribes of Alaska
Tribal Child Support Unit • Andrew Hope Building
320 West Willoughby Avenue, Suite 300 • Juneau, Alaska 99801
Tlingit & Haida Tribal Child Support Application
TCSU Application for Services 2020 2
Children concerned with Child Support for (add pages if necessary)
Compl
ete the following information for each child. Attach Birth Certificate to Application
You are the: Mother Father Relative _________________ Legal Custodian by court order ____________________
SSN
Child Full Name
Sex
DOB
Place of Birth
Mother’s Name
Father’s Name
Is there split custody? Yes No If Yes what % do you have the child(ren)_____________
Information on Other Parent- Mother Father:
Name (Last, First, Middle)
Previous/Other Names
SSN
Date of Birth
Address (PO or Street)- Residential
City
State/Zip
Current Address?
Yes No
Last Known as of
_________________
Address (PO or Street)- Mailing
City
State/Zip
Telephone (Home)
(Work)
(Message or Cell)
Email Address
Enrolled Member of CCTHITA? Yes No If enrolled with another tribe indicate name: ___________________________
Place of Birth
Race
Sex
M F
Color of Eyes
Color of Hair
Height
Weight
Does this person have relatives in Alaska? Who and where _________________________________________________________________
Does this person have an attorney regarding child support? Yes No Who? ________________________ Phone # _________________
Is this Parent Deceased?
Yes No If yes, Date of Death ___________________ City/State______________________________________________
Is estate in probate? Yes No If yes, who is Trustee? ___________________________________ Phone # _____________________
Other Parent’s Employer
Usual occupation _____________________________ Are they a Union Member?__________________________
Does this person work in Alaska currently? Yes No I don’t know
Did this parent used to work in Alaska? Yes No If Yes, when did they leave Alaska?_____________________
What was their last address in Alaska?______________________________________________________________
Current or last Known Employer
Employer Address
Employer Phone
Dates of Employment
Does this Parent have Health Insurance available through Employer, Union, or Indian Health
Services (IHS)? Yes No I don’t know
If yes, name of Insurance Company or IHS ____________________________________
Phone number of Insurance Company or IHS _________________________________
If yes, Type of Coverage
Medical Dental
Both Other ____________
TCSU Application for Services 2020 3
Other Parent’s Income or Assets
Does this Parent have other income? Yes No
If yes, Type of Income: Retirement Veterans Social Security Other __________________________________________
Does this Parent have Native Shares/Dividends?: Yes No If yes, Where: ________________________________________________
Do the children receive benefits based on a disability from this Parent ? Yes No
If yes, Source of Disability Benefit: ___________________________________________________ Monthly amount _______________
Does this Parent have a bank account? Yes No
If yes, Bank Name: _________________________________________________________ Account #: ____________________________
Bank Name: _________________________________________________________ Account #: ____________________________
Does this Parent have a vehicle? Yes No If yes, License #: ____________________________
Make: ____________________________ Model: _______________________ Year: ___________ Color: _______________________
Does this Parent have Property? Yes No If yes, Where: _________________________________________________________
List any other information that could assist TCSU to locate this Parent (Names/Addresses/phone numbers of relatives, friends, creditors and
schools attended, any known arrests, etc…
______________________________________________________________________________
______________________________________________________________________________
Relationship Between Parents (Attach documentation)
Divorced
Date of Separation ________________ Date of Divorce __________________
Court Case # _____________________
City/State _______________________________________________________
Attach a complete copy of the divorce decree/order
Married but Separated
Marriage Date ________________ City/State __________________________
Separation Date ______________
Divorce/Dissolution pending
Date filed ________________ Separation Date ___________________
City/State _______________________________ Court Case # _____________
Never Married
Separation date (if parents lived together) ____________________________
Child: __________________ Did father sign an Affidavit of Paternity Yes No
Is the father’s name on the birth certificate Yes No
In what state was the birth certificate issued _______________
Child: __________________ Did father sign an Affidavit of Paternity Yes No
Is the father’s name on the birth certificate Yes No
In what state was the birth certificate issued _______________
Child: __________________ Did father sign an Affidavit of Paternity Yes No
Is the father’s name on the birth certificate Yes No
In what state was the birth certificate issued _______________
Attach complete copy of the Affidavit of Paternity
Other (explain) ___________________________________________________________________________________________
TCSU Application for Services 2020 4
Child Support Information (Attach Documentation)
Is there an order that requires payment of child support? Yes No If yes, Order #: ___________________________________________
Type: Court Order Paternity Temporary Order Administrative Order
Tribal Other _____________________________________
Was child support payment made through a third party? Yes No
Who: State Tribe Court Clerk or Prosecutor’s Office Other ___________________________________
City/Tribe/State Name: __________________________________________ Date: __________________ Phone#: _______________
Additional Monthly Costs incurred on the behalf of child(ren) (Attach documentation)
Health Ins., how much ___________ paid by _________ Dental Ins., how much __________ paid by _________
Education, how much ___________ paid by _________ Medical, how much ____________ paid by _________
Other __________________, how much __________ paid by _________
Check here if you paid child support and list in the table below payments made either directly or through third party
Child support received from Mother Father [Please check box same as Information on Other Parent]
Check here if you have not received Child Support
Check here if you have received child support .List in the table below the payment you have received directly.
Check here if aren’t sure how much child support you’ve received. List your best estimate by month and year.
Mo/Year
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
TOTAL
Certification
I agree to tell the Tribal Child Support Unit of any new or changed information that relates to the child support case
and collection/payment of child support. By submitting this application for child support, I understand that I am also
applying for State IV-D services for purposes of submitting arrearages for Federal tax refund offset.
I declare under penalty of perjury, under the laws and ordinances of this Tribe that the foregoing is true and correct.
_________________________________________ ______________________
Signature Date
click to sign
signature
click to edit
TCSU Application for Services 2020 5
Instructions for Completion of Paternity Witness Statement
The CCTHITA Tribal Child Support Unit (TCSU) will start an action to establish paternity if the father is not listed on each
birth record. If you are the Mother of the children, YOU MUST fill out the following Paternity Witness Statement for
each child. If you are a 3
rd
party (not Mother or Father) and are applying for services, you DO NOT need to
complete this form.
• Read each question carefully and answer all the questions as best as you can.
• Please use ink to answer each question.
After you complete the Paternity Witness Statement(s):
• Sign the form(s) in front of a “Witness”. This would be an adult that watched you sign the form and verified your
identification.
• Be sure the “Witness” completes their portion – at the bottom of the form.
TCSU Application for Services 2020 6
PATERNITY WITNESS AFFIDAVIT
Petitioner: TCSU Case No:
Central Council Tlingit & Haida Indian Tribes of Alaska
Tribal Child Support Unit
A Separate Statement is required for Each Child needing Paternity Established
(Use the back of the form if additional space is needed)
1. I, ______________________________________________, on oath, under penalty of perjury depose and allege:
I am the natural mother of the child named below.
Child’s Full Name (First, Middle, Last)
Child’s Date of Birth
Child’s Gender
Place of Birth, (City, County, State)
Date Mother Pregnant (Month, Date, Year)
Full Term Pregnancy Yes No
(If no explain)
Where Mother Got Pregnant (City, County, State)
The child was conceived as a result of sexual intercourse between ___________________________________and me during the time stated
above.
a. A man is named as the father on the child’s birth certificate. Yes No
If Yes, the man’s name and address are:
If the child was born in another state or country, you must send TCSU a copy of the birth certificate.
b. I was married at the time of this child’s birth. Yes No. (If Yes, complete the following).
A. Husband’s name (first, middle, last) and last known address: _______
______________________________________________________________________________________
B. State why husband is not the father of this child and send all appropriate documents, including divorce decree, genetic test
results and prior findings of non-paternity, if any.
________
c. Genetic tests were completed to determine the father of the child. Yes No
If Yes, send results, explain outcome, and list name(s) and address(es) of man/men tested:
________________
2. I had sexual intercourse with another man (other than the man I am naming as the child’s natural father) during the time 30 days before or 30
days after the child was conceived. Yes No (If Yes, complete the following).
a. The name(s) and address(es) of the other man/men:
b. The other man/men are biologically related to the man I am naming as the child’s natural father. Yes No
If Yes, state the biological relationship (e.g., brother, cousin, uncle, etc.)
c. I do not believe the other man/men is/are the father because:
All of the information and facts contained in this AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY are true and correct to my
best knowledge and belief. I agree to submit myself and, if I am the custodian, my child to genetic testing as may be necessary to
establish paternity.
____________________________ ______________________________________________________
DATE SIGNATURE (Do not sign unless you are before a witness)
Witness (Print Name) _________________________________________ Witness Signature ________________________________________
Date Signed _______________ Address of Witness _________________________________________Telephone # of Witness____________
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Tlingit and Haida Indian Tribes of Alaska Tlingit (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 26 January 2021

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