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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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  • 81 check-boxes
  • 201 other fields

Country of origin: US
File type: PDF

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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1
TCSU NTANF Application 2020
You Are the: Custodial Parent Non-Custodial Parent Foster Care
Third Party (fill out applications for each parent Mother Father)
Third Party’s Relationship to the Child: _____________________________________
Please answer each question as fully as possible. Print or type all answers. If you do not know an answer,
put “UNK” or if a question is not applicable put N/A. If you need more space, use a separate sheet and
attach it to this form. Complete a new application for each parent that is out of the household.
Important Information: If you receive NTANF, TCSU will continue to enforce child support for you
even after the NTANF grant has closed until you submit a withdrawal from services form to our office.
If you are denied NTANF, TCSU will NOT open a child support case on your behalf.
Information about You:
Name (Last, First, Middle)
Previous Names
SSN
Date of Birth
Mailing Address
City
State/Zip
Sex
M F
Physical Address
City
Telephone (Home)
(Work)
(Message or Cell)
Are you enrolled or eligible to be enrolled with Tlingit & Haida? Yes No
If enrolled with another tribe indicate name:
_____________________________________________________
Are the children enrolled or eligible to be enrolled with Tlingit & Haida? Yes No
If enrolled with another tribe indicate name:
_____________________________________________________
Are you receiving or have you ever received TANF/Cash Assistance? Yes No If yes, When?
______________________
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:
__________________________________________________________
Information about the Children (add pages if necessary):
Attach a copy of each child’s birth certificate to the application.
Is father listed on each birth certificate of each child? Yes No
If No, complete the appropriate paternity witness statement. Paternity witness statements are attached.
SSN
Child Full Name
Sex
DOB
Place of
Birth
Mother’s Name
Father’s Name
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 Unit
Child Support Information (NTANF)
2
TCSU NTANF Application 2020
Child Support Information (attach documentation)
Is there split custody? Yes No If Yes what % do you have the child(ren)_____________.
Is there an order that requires payment of child support? Yes No If yes, Order #:
_______________________________
Who issued the order(s): State court (any state) Tribal court State administrative agency (e.g. CSSD)
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 Tlingit & Haida? 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 ____________
3
TCSU NTANF Application 2020
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
_______________
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 the Parents (attach documentation)
Divorced
Date of Separation ________________ Date of Divorce __________________
Court Case # _____________________ City/State ___________________________________
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
Child: __________________ Did father sign an Affidavit of Paternity Yes No
Is the father’s name on the birth certificate Yes No
Child: __________________ Did father sign an Affidavit of Paternity Yes No
Is the father’s name on the birth certificate Yes No
Other (explain)
___________________________________________________________________________________________
Check here if you paid child support for any of the children listed in this application.
Check here if you have received child support for any of the children listed in this application.
Check here if you have not received any child support for any of the children listed in this application.
4
TCSU NTANF Application 2020
ASSIGNMENT OF SUPPORT
When you receive NTANF you must sign over to the Tribe any child support or spousal support payments owed to
you for any month in which you receive assistance. If the non-custodial parent pays child support while you are
receiving NTANF, you MUST turn the support payments over to TCSU. This is true even if there is no child support
order in effect.
If TCSU sends a child support payment to you in error, they will contact you to arrange
repayment of that money. If you want to repay the overpayment gradually out of future child
support payments, instead of immediately in a lump sum, check this box.
I understand that by signing below, I assign to the tribe any child support payments owed for any month in which I
receive assistance. 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.
I declare under penalty of perjury, under the laws and ordinances of this Tribe that the foregoing is true and correct.
________________________________________________________ ______________________
Signature Date
SUPPLYING INFORMATION TO TCSU – SAFETY CONCERNS
You are required by law to give TCSU information to get child support for a child receiving NTANF. This means you will
be asked to identify the non-custodial parent and where he or she lives and works. You must help TCSU establish paternity
if the child has no legal father, whether or not you are an intact family. If you are receiving NTANF, any money you
receive from the non-custodial parent for child support must be given to the Tribe through TCSU.
If you believe that enforcing child support will bring harm to you or your children, and you can provide support for your
belief, you may claim good cause by marking the 2
nd
option below. You will be asked by your Tribal TANF caseworker to
provide documentation to support your “Good Cause” Claim.
1. I agree to cooperate with TCSU (sign below and complete the rest of this form)
2. I believe I have good cause to not cooperate with TCSU (sign below and provide documentation; court order, police
reports, medical reports, etc.)
Cooperation with TCSU is required or you must have good cause not to cooperate. If you do not cooperate and you
do not have good cause; your NTANF assistance payment may be reduced and sent to a NTANF approved third party
for your family. TCSU will continue to pursue child support against the non-custodial parent, even if you do not
cooperate, unless the NTANF approves good cause. By submitting this application, I understand that I am also applying
for State IV-D services for purposes of submitting arrearages for Federal tax refund offset.
Signature _______________________________________________ Date ____________________
PLEASE DO NOT FILL OUT - TANF STAFF ONLY
IF Option #2 above was checked please fill out the following:
Good Cause Granted Reason: ________________________________________________
Was documentation received? Yes No If Yes, attach copies.
Good Cause Denied Reason Claimed: ___________________________________________
WDS/WDT Signature_______________________________________ Date ___________
TANF Supervisor Signature
__________________________________ Date____________
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5
TCSU NTANF Application 2020
PATERNITY WITNESS STATEMENT – Mother
INSTRUCTIONS: Complete this Statement if you are the mother of a child listed in this document and that child’s
birth certificate does not list a father or lists a person you believe is not that child’s father. A separate Statement is
required for EACH child needing paternity established. (Use the back of the form if additional space is needed.)
I, _______________________________________, declare under penalty of perjury that the following is true and
correct: 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 Got Pregnant
(Month/Year)
Full Term Pregnancy Yes No
(I
f No,
explain.)
Where Mother Got Pregnant (City, 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, provide the man’s name and his last known address:
________________________________________________________________________________
b. I was married when this child was born. Yes No If Yes, complete the following.
Provide your (then) husband’s name and his last known address:
________________________________________________________________________________
And, explain why your (then) husband is not the father of this child. Provide any relevant documentation
(e.g. divorce decree, genetic test results etc.).
________________________________________________________________________________
c. Genetic testing has been completed on this child and the results show:
________________________________________________________________________________
d. I had sexual intercourse with another man (other than the man I am naming as this child’s father) 30 days
before or after this child was conceived.
Yes No If Yes, complete the following.
Provide the name(s) and last known address(es) of the other man(men).
________________________________________________________________________________
The other man/men are biologically related to the man I am naming as the child’s father. Yes No
If Yes, state the biological relationship. _______________________________________________________
I do not believe the other man/men is/are the father because:
________________________________________________________________________________
All of the information and facts contained in this PATERNITY WITNESS STATEMENT are true and correct to my best
knowledge and belief. I agree to submit myself and, if I am the custodian, the child identified in this STATEMENT, to
genetic testing.
____________________________ __________________________________________________
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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6
TCSU NTANF Application 2020
PATERNITY WITNESS STATEMENT – Alleged Father
INSTRUCTIONS: Complete this Statement if you believe you are the father of a child listed in this document but are
not listed on that child’s birth certificate. A separate Statement is required for EACH child needing paternity
established. (Use the back of the form if additional space is needed.)
I, _______________________________________, declare under penalty of perjury that the following is
true and correct: I am the natural father 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 Got Pregnant (Month/Year)
Full Term Pregnancy Yes No
(If No, e
xplain.)
Where Mother Got Pregnant (City, State)
The child was conceived as a result of sexual intercourse between __________________ and me during the
time stated above.
The following facts support my belief and statements that I am the father of this child:
a. The mother and I lived together. Yes No
b. The mother told me I am the father of the child. Yes No
c. I am named as the father on the birth certificate. Yes No
d. I signed an acknowledgment of paternity Yes No
e. I was present at the birth of the child. Yes No
f. I visited the child at the hospital following birth. Yes No
g. I offered to pay for abortion/medical expenses. Yes No
h. I paid for birth related expenses. Yes No
i. I claimed the child on tax returns. Yes No
j. I have provided food, clothing, gifts or financial
support for the child. Yes No
k. I lived with the child. Yes No
l. I visited the child. Yes No
m. The child resembles me. Yes No
n. There are witnesses to my relationship with the
Child’s mother. Yes No
If yes, list names and addresses and briefly describe relevant facts known by each:
All of the information and facts contained in this PATERNITY WITNESS STATEMENT are true and correct to my best
knowledge and belief. I agree to submit myself and, if I am the custodian, the child identified in this STATEMENT, to
genetic testing.
____________________________ __________________________________________________
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 18 November 2021

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