DELAWARE HEALTH AND SOCIAL SERVICES - DIVISION OF CHILD SUPPORT ENFORCEMENT APPLICATION INSTRUCTIONS Please complete the entire application, attach all required documents, and sign before a Notary. (Notary services are provided free of charge at DCSE offices.) Complete a separate application for each non-custodial parent from whom you seek support. A $25.00 application fee is required (payable by check or money order) - unless you: (1) currently receive Medicaid, General Assistance, Food Stamps, or Child Care Subsidy, (2) have previously received federally funded Foster Care services, Temporary Aid to Needy Families (TANF), Medicaid, or (3) the child for whom you seek support is enrolled in a federal Head Start program. In addition, the Deficit Reduction Act of 2005 §454(6)(B), requires DCSE to charge an annual processing fee of $25 for each child support case in which the applicant has never received TANF assistance. DCSE will deduct this fee from child support payments to the custodial party after collections of at least $500 in each federal fiscal year (Oct. 1 – Sept. 30). PROCEDURES DCSE will accept your application regardless of age, color, disability, ethnicity, gender, nationality, race, religion, or sexual orientation. DCSE will make every effort to establish paternity and child support orders in a timely manner through the Family Court of the State of Delaware. Your cooperation in providing all required information, as well as your involvement in this process, is necessary. DCSE utilizes all appropriate remedies to enforce child support orders including issuance of income withholding orders, interception of tax refunds, and license suspensions. Enforcement remedies are automatically activated according to case account status. DCSE will attempt to collect arrears owed to the state of Delaware until paid in full. OFFICE LOCATIONS NEW CASTLE COUNTY Churchman’s Corporate Center 84-A Christiana Rd. New Castle, DE 19720 (302) 577-7171 KENT COUNTY Carroll’s Plaza, Suite 101 1114 S. DuPont Hwy. Dover, DE 19901 (302) 739-8299 SUSSEX COUNTY 9 Academy St. Georgetown, DE 19947 (302) 856-5386 Please submit your completed & notarized application to your local DCSE office. In New Castle County, applications should be mailed to P.O. Box 15012, Wilmington, DE 19850. WEBSITE: www.dhss.delaware.gov/dcse DCSE USE ONLY: Date application requested: ______________________ Date application mailed: ______________________ Date application received: ______________________ APPLICATION FOR CHILD SUPPORT SERVICES NONDISCLOSURE OF INFORMATION (to protect address information): Is there a Protection From Abuse (PFA) order preventing the release of your address?____________________________________________ If no, would the safety or liberty of you or your child(ren) be unreasonably put at risk by the release of your address or other identifying information? __________________________________________________________ REQUIRED DOCUMENTS I understand that the verification of certain information is required in order for my case to be processed. I have provided or will provide copies of the documents listed below, if they are appropriate in my case. I understand that failure to provide copies of these documents will delay the processing of my case. I am attaching -or- I will provide the following documentation: - Birth Certificate for each child - Acknowledgement of Paternity Form - Original and modified support orders... (including divorce decrees and custody orders) Orders established outside of Delaware must be certified by the Court in which they were established. - Certified payment history/arrears statement, if order is established - Copy of marriage license and divorce decree (if applicable) - Copy of social security cards for each case member - Protective order preventing release of address (if applicable) - Copies of applicant’s three (3) most recent: Pay stubs or W-2 forms SECTION I: CUSTODIAL PARTY INFORMATION Name: ______________________________________________________________________ (Last) (First) (Middle Initial) Social Security Number: _____________________________________________________ Address: ____________________________________________________________________ (Street) (City) (State) (Zip Code) Home Phone Number: __________________________________________________________ Cell Phone Number: __________________________________________________________ Date of Birth: _____________________________________________________________ Maiden/Previous Name(s): ____________________________________________________ Race: ____________________________ Sex: ____________________________ Employer: ___________________________________________________________________ Work Phone Number: __________________________________________________________ Employer Address: ___________________________________________________________ 1. What is your relationship to the non-custodial parent? - Never Married - Currently Married - Separated - Divorced - Other 2. If Married, Date of Marriage: __________________________________ State & County Where Married: _____________________________ State of last shared address: _____________________________ 3. Date and Place of Divorce/Separation: __________________________ Court: _____________________________ County: _____________________________ State: _____________________________ 4. If separated, has a private attorney started divorce proceedings and/or is court action currently pending? _________________________________________ If yes, please list name, address, and phone number of the Attorney and the County and State in which the court action is pending: Attorney: _________________________________________ Address: _________________________________________ Phone: _____________________________ Court: _____________________________ County: _____________________________ State: _____________________________ 5. Do you have a court order for child support already established? If yes, please provide the Court, County, and State in which the order was established, along with a copy of the support order. Court: _____________________________ County: _____________________________ State: _____________________________ 6. Have you ever received Temporary Assistance for Needy Families (TANF-formerly AFDC), State Medical Assistance, or previously applied for Child Support Services? If yes, indicate type of service, County and State: _______________________ SECTION II: CHILD(REN) 1. Child’s Name: __________________________________________________________________ (Last) (First) (Middle) Date of Birth: _____________________________________ Social Security Number: ____________________________ Sex: ____________________________ City & State of Conception: ________________________ City & State of Birth: ____________________________ Race: ____________________________ Your relationship to the child: ________________________________________________ Were the parents married to each other at the time of the child’s birth?________ If the parents were not married, is the father’s name is on the birth certificate? _____________ Was the mother married to anyone at the time of the child’s birth? _____________ If yes, indicate name of husband: ______________________________________ Date of Marriage: _____________________________ County & State: _____________________________ If the parents were not married when the child was born: Has paternity been established for the child? ______________________________ Was genetic testing done? __________________________________________________ Was a “Voluntary Acknowledgement of Paternity” signed? _____________________ If you answered yes to any of the above, indicate the date and in which County and State: ____________________________________________________________________________________ Is there an existing child support order for this child? ___________________ If yes: Amount $ Per Effective Date: _______________________________________ Name of Court: _____________________________________________________ County & State: ____________________________________________________ Are the child’s parents divorced? _____________________________ If yes, date, County and State divorce order was entered: __________________ 2. Child’s Name: __________________________________________________________________ (Last) (First) (Middle) Date of Birth: _____________________________________ Social Security Number: ____________________________ Sex: ____________________________ City & State of Conception: ________________________ City & State of Birth: ____________________________ Race: ____________________________ Your relationship to the child: ________________________________________________ Were the parents married to each other at the time of the child’s birth?________ If the parents were not married, is the father’s name is on the birth certificate? _____________ Was the mother married to anyone at the time of the child’s birth? _____________ If yes, indicate name of husband: ______________________________________ Date of Marriage: _____________________________ County & State: _____________________________ If the parents were not married when the child was born: Has paternity been established for the child? ______________________________ Was genetic testing done? __________________________________________________ Was a “Voluntary Acknowledgement of Paternity” signed? _____________________ If you answered yes to any of the above, indicate the date and in which County and State: ____________________________________________________________________________________ Is there an existing child support order for this child? ___________________ If yes: Amount $ Per Effective Date: _______________________________________ Name of Court: _____________________________________________________ County & State: ____________________________________________________ Are the child’s parents divorced? _____________________________ If yes, date, County and State divorce order was entered: __________________ 3. Child’s Name: __________________________________________________________________ (Last) (First) (Middle) Date of Birth: _____________________________________ Social Security Number: ____________________________ Sex: ____________________________ City & State of Conception: ________________________ City & State of Birth: ____________________________ Race: ____________________________ Your relationship to the child: ________________________________________________ Were the parents married to each other at the time of the child’s birth?________ If the parents were not married, is the father’s name is on the birth certificate? _____________ Was the mother married to anyone at the time of the child’s birth? _____________ If yes, indicate name of husband: ______________________________________ Date of Marriage: _____________________________ County & State: _____________________________ If the parents were not married when the child was born: Has paternity been established for the child? ______________________________ Was genetic testing done? __________________________________________________ Was a “Voluntary Acknowledgement of Paternity” signed? _____________________ If you answered yes to any of the above, indicate the date and in which County and State: ____________________________________________________________________________________ Is there an existing child support order for this child? ___________________ If yes: Amount $ Per Effective Date: _______________________________________ Name of Court: _____________________________________________________ County & State: ____________________________________________________ Are the child’s parents divorced? _____________________________ If yes, date, County and State divorce order was entered: __________________ SECTION III: MEDICAL SUPPORT Do you or your child(ren) currently receive Medicaid? ___________________ Do you have insurance available that covers the child(ren) for whom you are applying: Name of Health Insurance Company: _______________________________ Policy#: ________________________________________________________ Health Insurance Cost $________/Monthly Persons Covered: ________________________________________________ Name of Dental Insurance Company: _______________________________ Policy#: ________________________________________________________ Dental Insurance Cost $________/Monthly Persons Covered: ________________________________________________ When a support order is entered or modified, DCSE must seek to ensure that one or both of the parents isresponsible for providing health insurance (whether or not it is currently available) for the child(ren). Medical support will only be enforced against the parent responsible for the coverage if health insurance is determined to be available at a reasonable cost. SECTION IV: NON-CUSTODIAL PARENT (NCP) INFORMATION Name: ___________________________________________________________________ (Last) (First) (Middle) Social Security Number: _________________________________________________ Address: ________________________________________________________________ (Street) (City) (State) (Zip Code) This address is: - Current - Last known as of Home Phone Number: _________________________________________ Cell Phone Number: _________________________________________ Date of Birth: _________________________________________ City/State of birth: _________________________________________ Previous/Alias Name(s): ________________________________________ Race: ________________________________ Sex: ________________________________ Eye Color: ________________________________ Hair Color: ________________________________ Height: ________________________________ Weight: ________________________________ Employer: ________________________________________________________ Employer Phone Number: ___________________________________________ Employer Address: ________________________________________________ (Street) (City) (State) (Zip Code) This employer is: - Current - Last known as of Current, or prior, military service? _____________________________ If yes, which branch: - Army - Navy - Air Force - Marines - Coast Guard - National Guard Has the non-custodial parent ever been in prison? _________________ If yes, date(s) of incarceration: ____________________________________ Name of Prison: _______________________________________________________ Address: _____________________________________________________________ (Street) (City) (State) (Zip Code) Does the non-custodial parent receive a pension, disability benefits, social security, or have any other source of income? If yes, indicate source: _______________________________________________ Amount: $ per __________________________________________________________ Does the non-custodial parent provide health insurance for the child(ren)? _________ If yes, name of insurance company: _____________________________________ Policy Number: _________________________________________________________ AFFIDAVIT OF PAYMENTS: (Complete this section only if you currently have a child support order.) Custodial Parent: _____________________________________________________________ Non-Custodial Parent: _____________________________________________________________ List any agency that has collected child support payments on behalf of your child(ren): ______________________________________________________________________________________ Address: _____________________________________________________________________________ (Street) (City) (State) (Zip Code) Phone Number: __________________________________________________ Has the NCP ever made support payments directly to you?__________ If yes, list only those payments paid made directly. __________________________________________________________ Do not list payments received by an agency and forwarded to you according to the terms of the order. The information below is for the YEAR___________: Amount Owed Balance Amount Paid Jan ____________ ____________ ____________ Feb ____________ ____________ ____________ Mar ____________ ____________ ____________ Apr ____________ ____________ ____________ May ____________ ____________ ____________ Jun ____________ ____________ ____________ Jul ____________ ____________ ____________ Aug ____________ ____________ ____________ Sept ____________ ____________ ____________ Oct ____________ ____________ ____________ Nov ____________ ____________ ____________ Dec ____________ ____________ ____________ Totals ____________ ____________ ____________ Certification: I hereby certify that the statements I have given in this document are true and correct. I further agree to notify DCSE immediately of any changes in my address, telephone number, income, expenses, or employer. Applicant Signature: ______________________________________________ Date: _________________________________________ Sworn and subscribed before me this day of 20____. Notary Public Signature: _________________________________________ Date: _________________________________________ CERTIFICATION BY CUSTODIAN By signing this document, I agree to the following: 1. I understand that, under Family Court Civil Rule 87.2, a petition for new support will be filed in the county where the child[ren] and I reside. I may submit to DCSE a written request to file in a different county. If I elect to file my support petition in a county other than where the child[ren] and I reside, I agree to absorb all expenses associated with attending the hearing(s), such as travel expenses, parking fees, and childcare costs. 2. I will appear at all mediation conferences and Family Court hearings held in Delaware. I understand that failure to appear in Family Court for scheduled hearings or mediations may result in dismissal of the petition and/or sanctions that could affect the receipt of state assistance. 3. I will cooperate with DCSE by providing requested documentation. 4. I understand that all child support payments must pass through the DCSE State Disbursement Unit forproper accounting. I understand that the Non-Custodial Parent may not receive credit for payments delivered to me directly, and I will report any direct payments I received to a DSCE worker. 5. I understand that DCSE will utilize all available resources to recoup or recover payments sent to me in error, including but not limited to, withholding future child support payments. 6. I understand that I am required to notify DCSE in writing within five (5) days of any of the following events: • If I retain the services of a private attorney. • If I have a change in name. • If I move or change my address. • If the custody of the child[ren] changes and I am no longer the primary custodian. 7. I agree to have DCSE act on my behalf to enter into negotiations with the Non-Custodial Parent or his/her attorney to settle any child support claims I may have. I further request DCSE to file any necessary legal documents against the Non-Custodial Parent. Under Delaware law, a Deputy Attorney General who handles my case is deemed to represent the state agency, DCSE, and not me individually. 8. I will comply with DCSE requirements and administrative enforcements to effectively process my case. These services are available to me under the Child Support Enforcement Program: • Enforce support order • Establish child support order • Establish paternity • Establish medical (health insurance) order • Locate parent(s) responsible to provide support • Modify existing order Services will be implemented in accordance with my case status. I can stop services by notifying DCSE in writing. 9. Notice Regarding Use of Social Security Numbers (SSN): Federal child support mandates [42 USC §666(a)(13)] require the collection of SSNs for all individuals involved in paternity and child support orders. SSNs are used under the state’s child support enforcement program to locate individuals for purposes of establishing paternity and establishing, modifying and enforcing support obligations. Applicant Signature: _________________________________________ Date: _________________________________________ Sworn and subscribed before me this day of 20____. Notary Public Signature:_________________________________________ Date: _________________________________________ Copy to Custodial Party.