Application for Child Support Service - Idaho
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Application for Child Support Services
INFORMATION ABOUT THE CUSTODIAL PARENT (the parent or guardian who lives with the child)
1. Name
_____________________________________________________________________________________________________________
First Middle Last
2. Social Security Number _____/_____/______ Sex Female Male
3. Date and place of birth _____/_____/_____ _______________________________________________
Month Day Year Place of Birth
4. Home
Address ______________________________________________________________________________________________________
Street City State ZIP
5. Mailing Address (if different) __________________________________________________________________________________________
Street (or P.O. box) City State ZIP
6. Home Phone ( ) ________________ Work Phone ( ) ________________
7. Have you ever received cash assistance, such as AFDC or TAFI? Yes No
If yes, when and in which state? ________________________________________________________________________________________
8. Have you ever received Medicaid? Yes No If yes, when and in which state?____________________________________________
9. Does an attorney represent you on any matter related to the non-custodial parent? Yes No
If yes, please list the attorney’s name, address, and telephone number:
___________________________________________________________________________________________________________________
Name Street City State ZIP Phone Number
10. What is your relationship to the child? Parent Stepparent Grandparent Sibling Other ______________________________
11. Please list the name of a close friend or relative who always will be able to get in touch with you if we are unable to :
__________________________________________________________________________________________________________________
Name Street City State ZIP Phone Number
INFORMATION ABOUT THE NON-CUSTODIAL PARENT
(the parent who does not live with the child)
12. Name
_____________________________________________________________________________________________________________
First Middle Last
13. Social Security Number _____/_____/______ Sex Female Male
14. Date and place of birth _____/_____/_____ ______________________________________________________________________
Month Day Year Place of Birth
15. Home
Address ______________________________________________________________________________________________________
Street City State ZIP
16. Mailing Address (if different) ___________________________________________________________________________________________
Street (or P.O. box) City State ZIP
Is this address current? Yes No If no, or don’t know, address above was current as of _____/______/_____
Month Day Year
17. Home Phone ( ) ________________ Work Phone ( ) ________________
18. Physical description: Eye Color __________ Hair Color __________ Height __________ Weight _________
Race: Alaskan Eskimo Black White American Indian Hispanic Asian Other _____________________________
Other marks (tattoos, scars, etc.) ______________________________________________________________________________________
19. Who are this person's parents (even if deceased)?
Father’s Name _________________________________________ Mother’s Maiden Name______________________________________
20. Has this person ever been in the military? Yes No If yes, which branch? _______________________________________________
Current status _______________________ Base ________________________________________________________________________
Name City State ZIP
21. Has this person ever been in jail or prison? Yes No If yes, where? ____________________________ When? ________________
22. Is this parent working? Yes No
23. Where does the non-custodial parent work? If you don’t know, list the last known employer:
Company Name ____________________________________________________________________________________________________
Address __________________________________________________________________________________________________________
Street City State ZIP
Phone ( ) ____________________ If employment is not current, when did he/she last work there? _____/______
24. Does this person receive or qualify for SSI SSA/SSD VA benefits Workman’s Compensation Other _______________
25. Other information that may help CSS collect child support, such as other names used, additional employers, or assets this person may have
(bank accounts, automobiles, real property, etc.___________________________________________________________________________
__________________________________________________________________________________________________________________
OFFICE USE ONLY
Date Requested ___________________________
Date Provided ________________________________
Fee Paid __________ Date Received _ ___________
Receipt # ____________ Case # _______________
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