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HS-2912, Tennessee Application For Child Support Services is a comprehensive document requiring information about various persons and factors pertaining to the child(ren) and the subject of the request.


The Department of Human Services, State of Tennessee is the body in charge of the entire process. The application is divided into 7 major sections followed by the application. Filling details in the respective fields is necessary. Mention the Social Security Number/s of all individuals related to the child. As per section 466(a)(13) of the Social Security Act [42 U.S.C. 666(a)(13)], you must disclose SSN to Child Support Agency.


Information about the Applicant For child support services

  • Mention your role from selecting between the choices between PRP/Caretaker or ARP. Select between the choices of review or establishment of paternity in the next subsection if you are ARP.
  • Furnish the information about your parent/guardian name, address, and phone numbers in section 2 in case you are unmarried and under the age 18.
  • Mark your choice between yes or no in section 3 and proceed by furnishing supporting information in the space provided in subsequent lines in case response you mark is yes.
  • Enter the name of the county other than the one you dwell in case you mark your option yes instead of no. Leave blank if your response is no.

Information about the Primary Residential Parent (PRP) / Caretaker

  • Enter the first, middle, and last name of PRP followed by the maiden name if any.
  • Specify the relationship of caretaker with the child.
  • Mention the identifying information of PRP like date of birth, social security number, sex followed by mailing and living address including phone numbers at both addresses.
  • Furnish information about the employer of PRP in section 4. Mention name, address, and phone number.
  • Specify marital relationship between the ARP and PRP between choices yes or no and proceed with furnishing information about marriage, separation, and divorce dates; respective counties and states.
  • Provide the information of the child support service if any pursuant for child support. Enter the name of the entity/individual followed by address. Describe legal action if any, taken involving the child (ren) in the following line.
  • Complete the section 7 & 8 if you are PRP. Mention the nature of the benefit you are receiving if any along with the duration and name of the state if other than Tennessee. Furnish the information of alternate contact person’s name, phone number, and relationship in case you are not reachable for child support service.

Information about the Alternate Residential Parent (ARP)

  • Furnish name of ARP along with the maiden name and alias if any. Continue furnishing the relationship of ARP with the child (ren) on the following line.
  • Enter home, work and cell phone numbers of ARP in the spaces provided for the same along with the area code as applicable.
  • Furnish current/ last known mailing and living address of ARP and specify if it is a good address or not.
  • Mention the employment status of ARP followed by the nature of occupation.
  • Continue with entering the information about the current and previous employer along with phone numbers in the respective fields.
  • Furnish general information about ARP like SSN, birthplace, date of birth, age, driver’s license number and state, sex, race, height, weight, hair color, eye color, distinguishing marks, known disabilities, and any other relevant information. Specify if a photograph of ARP is provided.
  • Specify the name and address of the institution along with the expected release date if ARP is in jail or prison.
  • Provide the name of parole/probation officer name and address if the ARP is on probation or parole. Mark your selection by selecting the appropriate box.
  • Furnish the date/duration of service and branch if ARP served in armed forces. Specify whether the ARP retired from the military or reserves by selecting the appropriate box.
  • Mark your choice yes, if ARP receives a pension and/or benefits from the federal government. Specify the source of income and approximate income from each source in the subsequent lines.
  • Furnish details of assets held by ARP. Mention the make, model, year, color, license plate number, and state of motor vehicles owned by ARP. In addition, provide information about bank accounts, real estate, and other assets in the spaces provided for the same.
  • Enter the information about other/additional contacts of ARP. Mention names of mother, father, friends, and relatives along with their addresses.

Court Order Information

Mark your choice yes for the court order if any. Furnish the details like name of the court issuing the order, date of the order, docket/case number, county and state, mode of payment, amount, frequency of pay, due date of the pay along with the date and amount of last pay received. Mention arrearage amount if any. Filling these details is necessary when you record your response yes of the court order for child support.

Additional Information

Furnish any additional information you feel relevant during seeking the child support. Mention the names of possible father/s if any. You can attach a separate sheet if needed for furnishing additional information.

Information about the Child (Ren)’S Medical Support

  • Mark your choice about who provides medical insurance for the child. Mark your choice between mother, father, both, or neither of them in the spaces provided.
  • Mention carrier name, policy number, and insured’s name. Mention carrier name if other than TennCare. Enter the monthly insurance premium and the number of family members covered under the policy.
  • Furnish the names of child(ren) covered under the policy. Use a separate line to mention the name/s of each child.
  • Provide itemized details of unpaid medical bills if any along with copies of the bills.
  • Furnish the copy of clarification of the benefits from the insurance company if you have submitted the unpaid medical bills to the insurance company.
  • Provide information if you have submitted unpaid medical bills to any other party. Provide a copy of unpaid medical bills to the other party immediately if you have not.
  • Mention the details of any recurring medical expenses not covered under the health insurance after selecting yes from the options. Leave blank if you select no.

Information about the Child (Ren)

Section VII of the HS-2912, Application for Child Support Services requires input of each child in a separate section for whom you are seeking child support services. Attach a copy of the birth certificate of each child along with HS-2912 form. You may choose to attach additional sheets if necessary.

  • Enter child’s last, first, and middle name in the spaces provided for the same.
  • Type the social security number and date of birth of the child in the space on the following line.
  • Mention the city, county, and state of the birth of the child.
  • Select between yes or no to state whether the child’s parents were married at the time of the birth of the child. Tick mark in the appropriate box.
  • Mention if the mother of the child was married to another person at the time of the birth of the child. Mark your choice of yes or no.
  • Select yes or no to confirm if the paternity established when the child born out of wedlock.
  • State the cause of establishing paternity if your choice is yes. Select the appropriate choice between voluntary acknowledgment, court order, or select others and describe in the space provided.
  • Mark your choice of yes or no if the health/medical insurance policy of ARP covers the child too.

Application

Enter your name in the space provided on line 1 of the application. Read the undertaking carefully and proceed with signing at the bottom in acceptance of the undertaking followed by entering the date to complete and submit form HS-2912, Application For Child Support Services to the Department of Human Services, State of Tennessee.

Tennessee Child Custody Form

Text Version of this Form

———————– Page 1———————–

STATE OF TENNESSEE

DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR CHILD SUPPORT SERVICES

It is this agency’s desire to act in the best interest of you and your child(ren) at all times. Therefore, we want to give you some

important information regarding how your case will be handled.

INFORMATION YOU NEED TO KNOW

• You must notify us immediately if you move or change your telephone number.

• Your cooperation is required.

• You must return any money sent to you in error.

• You must notify us in writing if you wish to cancel services.

WE CAN ATTEMPT TO

• Locate a parent whose whereabouts are unknown,

• Establish paternity for a child,

• Establish and enforce court orders for child support payments, unpaid medical bills, and/or medical insurance,

• Review and modify child support orders, and

• Collect child support arrears using a variety of enforcement methods, including intercepting federal income tax refunds.

WE CANNOT

• Guarantee that our attempts to establish or enforce child support will be successful,

• Handle matters that are not related to child support such as divorce, visitation or custody disputes, or

• Give your case priority over any other cases we have.

AFTER WE RECEIVE YOUR COMPLETED APPLICATION, WE WILL

• Review your case,

• Decide the proper action to take on your case, and

• Make every effort to provide the needed service.

IN ADDITION

• We will contact you if we need additional information from you, and to inform you of appointments and court hearing

dates.

• Your signature on the application form indicates your agreement that the agency may file a legal action in your case and

may close your case if you do not cooperate.

• Our attorneys represent the State of Tennessee. They will help provide you with child support services, but they do not

represent you or any other individual.

• Case information will be given out only for child support purposes.

• All child support payments will be processed through the Central Payment Processing site in Nashville, Tennessee.

———————– Page 2———————–

State of Tennessee

Department of Human Services

Information Gathering Letter

NOTE: Each individual’s Social Security number (SSN) is a critical part of case processing. Based on section 466(a)(13) of the Social

Security Act [42 U.S.C. 666(a)(13)], you are required to disclose Social Security numbers to the child support agency. They will be used by

the State’s child support enforcement program to locate individuals for the purposes of establishing paternity and establishing, modifying,

and enforcing support obligations. It is possible that your SSN and those of the child(ren) will be used to file interstate child support

enforcement actions and to enroll the child(ren) as beneficiaries of health insurance coverage, and, as such, may be released to the other

parent. The alternate residential parent’s SSN is necessary to properly identify that parent for the purpose of locating him/her, for submitting

cases for the Treasury Offset Program, and for other child support enforcement activities.

The information requested in this application must be provided by every applicant for child support services, regardless of whether they are

the primary residential parent / caretaker or the alternate residential parent of the child(ren). If you are the primary residential parent

(PRP) / caretaker, enter information about yourself in Section II and enter information about the alternate residential parent in Section III.

If you are the alternate residential parent (ARP), enter information about the primary residential parent / caretaker in Section II and enter

information about yourself in Section III.

I. INFORMATION ABOUT THE APPLICANT FOR CHILD SUPPORT SERVICES

1. Are you

The PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER of the child(ren) for whom services are requested

(The PRP is the parent with whom the child(ren) resides more than 50% of the time) NOTE: For the purpose of completing this application,

also check this box if the child(ren) for whom you are requesting services resides/reside with you exactly 50% of the time.

or

The ALTERNATE RESIDENTIAL PARENT (ARP) of the child(ren) for whom services are requested

(The ARP is the parent with whom the child(ren) resides less than 50% of the time)

If you are the ALTERNATE RESIDENTIAL PARENT (ARP), are you applying for

A review and modification of your support order, or

To establish paternity for the child(ren)?

NOTE: Any application for child support services will result in this agency taking action as needed to enforce support obligations.

2. Are you under age 18 and unmarried? Yes No If yes, provide the following information about your parent or guardian:

Last Name: _______________________________________ First Name : ________________________ Middle Name: ____________________

Address: _____________________________________________________________________________________________________________

City: _______________________________________________ State: ____________________________ Zip: ________________________

Phone (Home): (______)____________________________ (Cell): (______)_____________________ (Work): (_____)___________________

3. Do you have reason to believe that the ARP might try to harm you or the child(ren) if we try to contact him/her, or as the result of any action we

might take on your child support case? Yes No

If yes, please explain: __________________________________________________________________________________________________

___________________________________________________________________________________________________________________

4. Do you want this case to be managed by a child support office located in a county other than the one in which you live? Yes No

If yes, indicate which county: _______________________________________________ Granting this request is limited by jurisdictional law and

the location of child support offices.

FOR STATE USE ONLY

Foster care worker’s name: Phone:

Approval date: Social Services Number: IVE Case Number:

Page 1

———————– Page 3———————–

II. INFORMATION ABOUT THE PRIMARY RESIDENTIAL PARENT (PRP) / CARETAKER

If you are the primary residential parent (PRP) or caretaker of the child(ren), provide the following information about yourself.

If you are the alternate residential parent (ARP), complete this section with information about the primary residential parent (PRP) / caretaker.

1. Last Name: ___________________________________ First Name: _______________________________ Middle Name: _______________

Maiden Name: ________________________________

2. What is the caretaker’s relationship to the child(ren) (mother / father / grandmother / etc.)?

3. Identifying information for the primary residential parent (PRP) / caretaker

Date of Birth: ______/______/________ Social Security Number: ________-________-________ Sex: ______________

Address of the primary residential parent (PRP) / caretaker

MAILING address: __________________________________________________________________________________________________

City: ______________________________________ State: ______________ Zip: _______________ County: _______________________

Phone (Home): (_____)______________________ (Cell): (_____)_______________________ (Work): (_____)_______________________

LIVING address: ___________________________________________________________________________________________________

City: ______________________________________ State: ______________ Zip: _______________ County: _______________________

Phone (Home): (_____)______________________ (Cell): (_____)_______________________ (Work): (_____)_______________________

4. Primary residential parent (PRP)’s / caretaker’s employer: ____________________________________________________________________

Address: ____________________________________________________________________________ Phone: (______)__________________

City: ______________________________________________________ State: ____________________________ Zip: ______________

5. Has the primary residential parent (PRP) / caretaker ever been married to the alternate residential parent (ARP)? Yes No

If yes, provide any of the following information that applies:

Marriage Date: _______________________________________ County: __________________________ State: ____________________

Separation Date: ______________________________________ County: __________________________ State: ____________________

Divorce Date: ________________________________________ County: __________________________ State: ____________________

6. Is any other agency or attorney involved in pursuing child support at this time? Yes No

If yes, give the name of the agency/attorney: __________________________________________ Phone number: (_____)________________

Address: ___________________________________________________________________________________________________________

City: ________________________________________________ State: _____________________________ Zip: ______________________

Has there ever been ANY legal action involving this child(ren)? Yes No If yes, describe the action:_______________________________

Answer questions # 7 and 8 only if you are the primary residential parent (PRP) / caretaker of the child(ren)

7. Do you currently receive, or have you ever received public assistance, Families First, Medicaid, or TennCare benefits? Yes No

If yes, for what period of time? From : _________________________________ To: ___________________________________________

Did you receive these benefits in Tennessee? Yes No In which other state(s) did you receive these benefits? ___________________

8. Name and phone number of a person we can contact if we are not able to reach you.

Name: ____________________________________________________________________________________________________________

Phone number: (________)___________________________________________________ Relationship: ____________________________

Page 2

———————– Page 4———————–

III. INFORMATION ABOUT THE ALTERNATE RESIDENTIAL PARENT (ARP)

If you are the alternate residential parent (ARP), provide the following information about yourself.

If you are the primary residential parent (PRP) / caretaker, provide the following information about the alternate residential parent (ARP) of the

child(ren).

If you are applying for support from more than one alternate residential parent (ARP) you must complete a separate application for each alternate

residential parent (ARP). If different persons could possibly be the father of the same child(ren), make a note of this in Section V, Page 5 of this

application.

1. Last Name: First Name: Middle Name:

Maiden Name (if applicable):

2. Alias or nicknames: Last: First: Middle:

3. What is the alternate residential parent (ARP)’s relationship to the child(ren)? Father Mother

4. Phone number(s) for the alternate residential parent (ARP).

Home: (______)__________________________ Cell: (______)_______________________ Work: (______)______________________

5. Address of the alternate residential parent (ARP):

Current or last known MAILING address: ________________________________________________________________________________

City: _______________________________________________ State: ____________________________ Zip: ______________________

Is this a good/valid address? Yes No

Current or last known LIVING address: __________________________________________________________________________________

City: _______________________________________________ State: _____________________________ Zip: ______________________

Is this a good/valid address? Yes No

6. Is the alternate residential parent (ARP) self-employed? Yes No If yes, in what occupation? ______________________________

7. Alternate residential parent (ARP)’s current employer: ______________________________________________________________________

Address: _____________________________________________________________________ Phone number: (______)________________

City: _______________________________________________ State: ___________________________ Zip: _______________________

Alternate residential parent (ARP)’s previous employer:______________________________________________________________________

Address: _____________________________________________________________________ Phone number: (______)_________________

City: _______________________________________________ State: ____________________________ Zip: _______________________

8. General information about the alternate residential parent (ARP)

Social Security number Birthplace (city/county/state) Date of birth

Approximate age Driver’s license number (include state) Sex

Race Height Weight

Hair color Eye color Photograph provided?

Distinguishing marks Known disabilities Other information

Page 3

———————– Page 5———————–

9. Is the alternate residential parent (ARP) currently in jail or prison ? If yes, provide the following information:

Name of the institution: _________________________________________________ Expected release date: ____________________________

Address: _____________________________________________________________________________________________________________

City:________________________________________________ State: _____________________________ Zip: _______________________

10. Is this alternate residential parent (ARP) on probation or parole? If yes, provide the following information:

Parole or probation officer’s name: ________________________________________________________________________________________

Address: ___________________________________________________________________ Phone number: (______)____________________

City: _______________________________________________ State: _____________________________ Zip: ________________________

11. Has the alternate residential parent (ARP) ever served in the armed forces? Yes No If yes, which branch? _______________________

Dates of service: From: ________________________ To: ________________________________________________________________

Is the alternate residential parent (ARP) retired from the military or in the reserves? Yes No

12. Does the alternate residential parent (ARP) receive any pensions or benefits from the federal government (Social Security, SSI, VA, retired military,

etc.) or from other sources? Yes No

If yes, provide: Source (1): __________________________________________ Approximate monthly income amount _______________

Source (2): __________________________________________ Approximate monthly income amount ________________

Source (3): __________________________________________ Approximate monthly income amount ________________

13. Describe any assets the alternate residential parent (ARP) may own.

Make: Model: Year:

Cars, trucks, motorcycles

Color: License plate number: State:

Bank accounts:

Real estate:

Other assets:

14. Other contacts for the alternate residential parent (ARP). Give any information you have, even if it is incomplete:

Mother (first/middle/last name) Phone number:

Address/City/State Zip

Father (first/middle/last name) Phone number:

Address/City/State Zip

Friend or other relative (first/middle/last name) Phone number:

Address/City/State Zip

Page 4

———————– Page 6———————–

IV. COURT ORDER INFORMATION

Is there a court order for child support for the child(ren) for whom child support services are requested? Yes No

If yes, provide any information you have about the existing court order(s). Attach copies of the orders and payment records, if available.

Name of the court that issued the order Date of the order

Docket/case number County/State

How are payments made? (through court, IV-D agency, or directly to caretaker) Amount of support ordered

Pay frequency ordered (weekly, monthly, other, etc.) Payment due date

Date and amount of the last payment/collection Amount of the arrearage

V. Use the area below to provide any additional information about your case that you think the child support office may need, including the names

of any other possible fathers of the child(ren) for whom you are applying. (Add a separate sheet if needed)

VI. INFORMATION ABOUT THE CHILD(REN)’S MEDICAL SUPPORT

Which parent provides medical insurance for the child(ren)? Mother __________ Father __________ Both _________ Neither __________

Carrier name (excluding TennCare): ___________________________________________________________________________________________

Policy number: ____________________________________________ Insured’s name: _____________________________________________

Monthly insurance premium: _________________________________ Number of family members covered by policy: _____________________

Name(s) of the child(ren) who are covered by this policy

_________________________________________________________ ______________________________________________________

_________________________________________________________ ______________________________________________________

_________________________________________________________ ______________________________________________________

_________________________________________________________ ______________________________________________________

Do the child(ren) have any unpaid medical bills? Yes __ No __ (If yes, provide itemized detail and copies of all bills.)

Have you presented the unpaid medical bills to the insurance company? Yes __ No __ (If yes, provide a copy of the Explanation of Benefits

from the insurance company.)

Have you presented the unpaid medical bills to the other party? Yes __ No __ (If no, provide the other party a copy of the unpaid bills

now.)

Do the child(ren) have any recurring medical expenses not covered by Yes __ No __

health insurance?

Page 5

———————– Page 7———————–

VII. INFORMATION ABOUT THE CHILD(REN)

List below each of the children of the other parent shown on this application for whom you are requesting child support services. For each

child, provide all of the necessary information and a copy of that child’s birth certificate. Attach additional sheets if needed.

1. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

2. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

3. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

Page 6

———————– Page 8———————–

INFORMATION ABOUT THE CHILDREN (continued)

4. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

5. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

6. Child’s Last Name _____________________ First Name _______________________ Middle Name ____________

Social Security Number: ___________________________________ Date of Birth: ______________________________

City / County / State of Birth: _____________________________________________________________________________

a. Were the parents married to each other at the time of birth? Yes No

b. Was the mother married to another person at the time of birth? Yes No

c. If this child was born out of wedlock, has paternity been established? Yes No

d. If yes, was paternity established by:

voluntary acknowledgment, court order, other (please specify):

e. Is this child covered by the alternate residential parent (ARP)’s health/medical insurance policy? Yes No

Page 7

———————– Page 9———————–

APPLICATION

I, ____________________________, am applying for Child Support services provided by the Child Support Agency of the Tennessee

Department of Human Services. I understand and acknowledge the following:

1. The Child Support attorney handling my case represents the State of Tennessee, not me personally.

2. The information that I supply is the source for any petition filed for me.

3. The Child Support office will act to enforce the alternate residential parent (ARP)’s legal child support obligations. If the Child Support

office determines any action to be improper or unwarranted, it will not take that action.

4. If I give any information or testimony that a court finds to be false, the State may prosecute me for perjury.

5. If I get any money as the result of fraud on my part, I understand that the State may charge me with fraud. Also, the State may require me to

pay back any money that I get through fraud.

6. The Child Support office does not promise the success of any action, or results within a given time.

7. The services provided by the Child Support agency only include enforcing rights to child support, obtaining and enforcing health insurance

orders, establishing paternity, and in some limited cases, obtaining spousal support. These services do not include actions involving custody,

visitation, or similar issues. If such issues are raised in this case, I understand that I must secure other representation.

8. Since anyone in the State may apply for Child Support services, this means the Child Support office may provide services to others whose

interests conflict with mine.

9. I must pay filing fees or court costs if the court determines I am able to pay them. In addition, if I have never received Families First /

Temporary Assistance to Needy Families (TANF) benefits, the State will charge me a $25 annual fee for providing child support services,

but only after collecting at least $500 for my case in an annual period. To pay this fee, the State will keep the next $25 in child support that

it collects for my case after the initial $500. If my case requires action by another state, I must also pay any filing fees or associated costs

the other state requires for my case to proceed.

10. If I have received TANF or Families First benefits in the past, any support collected each month above the current support owed each month

will be kept by the State to repay the TANF/Families First benefits I have received.

11. If the child(ren) in this case receive Medicaid or TennCare, I must tell the Child Support office immediately.

12. If I get a private attorney to represent me in obtaining child support, I agree to tell the Child Support agency immediately.

13. My case will be submitted to the IRS Treasury Offset Program if it meets the following conditions:

A. A court or administrative agency has ordered the alternate residential parent (ARP) to pay support.

B. A copy of the order, and any changes to the order, are on file in the Child Support office. Also, there must be a copy of the court’s

payment record on file in the Child Support office. If there is no court payment record, I must give the Child Support office a signed

affidavit of the amount owed by the alternate residential parent (ARP).

C. The alternate residential parent (ARP) must owe at least $500.00 past due child support under such order.

D. The Child Support office has the Social Security number (SSN) of the alternate residential parent (ARP).

14. I further understand that if my case is submitted for the IRS Treasury Offset Program:

A. There is no guarantee that money will be collected on my behalf. A Treasury Offset Program collection through the Federal Tax

Refund Offset Program is only possible if the alternate residential parent (ARP) files a tax return and is due a refund from the IRS.

B. If money is collected through this process and a joint return is involved, the State has the right to hold the refund for six months before

sending any collections to me.

C. If I have received TANF or Families First benefits, the State will keep part or all of the refund to repay any TANF/Families First

benefits previously provided by the State.

D. The State has the right to withhold amounts from future IRS offsets if I do not voluntarily repay amounts paid to me in error.

E. The IRS charges a fee up to $25.00 for each collection made through the offset program. This fee will be deducted before I receive any

collection.

15. I must repay to the State any money that I am overpaid, or that is sent to me in error.

Some situations that can result in overpayment are: the State receives a child support payment by personal check or other payment method

that is later dishonored; the State must return amounts to the IRS because the alternate residential parent (ARP)’s spouse filed an amended

tax return; the State sends me a duplicate payment to replace a payment I did not receive, then I receive both payments; or, the State sends

me any payment that I am not entitled to receive. I agree to allow the State to recover any overpayments, without notice to me, by

withholding the overpaid amount from future child support that is processed. In addition, I will sign any agreement required by the

Department of Human Services for repayment of any such overpayments. If the State must seek action against me to recover such

overpayments or payments sent in error, I will pay the costs of such action, including court costs and attorney fees.

I swear or affirm that the information I have provided in support of this application is correct to the best of my knowledge, information, and

belief. I will cooperate with the Department of Human Services and the local Child Support office in the matter. Further, I swear or affirm that I

have read this affirmation and acknowledgment. I declare that I understand it fully and agree with the terms.

___________________________________________________________ ____________________________________________

Signature Date

Page 8

HS-2912 (Rev. 4/07)

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