Application for Child Support Service - Idaho
8
INFORMATION ABOUT YOUR CHILDREN
26. List the following information for each child included in this case. If there is not enough room, list additional children on a separate page.
Name (First, Middle, Last) Sex Date of Birth Social Security Number Placeof Birth
(County and State)
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
27. Has paternity been established for each child? Yes No If not, list children for whom paternity has not been established.
___________________________________________________________________________________________________________________
28. If you are pregnant, when is your baby due? _____/______/_____ Who is the father? _______________________________________
Month Day Year
MEDICAL INSURANCE INFORMATION
29. Who is providing medical insurance coverage for the children in this case? _______________________________________________________
Start date / Effective date: _______________________
___________________________________________________________________________________________________________________
Insurance Company Name Policy # Subscriber #
__________________________________________________________________________________________________________________
Street Address or P.O. Box City State Zip
YOUR LEGAL STATUS WITH THE OTHER PARENT
30. What is your current relationship to the other parent?
Married (Date) _______________ Divorced (Date) _______________ Separated Other ___________________________
31. Is there a divorce decree/support order for any of the children? Yes No If no, skip to question 35.
32. Which county and state set the order?___________________________________________________________________________________
County State
33. What is the court order number? (attach a copy) ______________ Date of your most recent court order ______/______/_____
Month Day Year
34. Amount of monthly current support ordered $_____________ Have any payments been missed? Yes No
If yes, how much past-due support is owed? $_____________ When was the last payment made? _____/______/_____
Month Day Year
REQUESTED SERVICES
35. Please check the service you would like to receive:
All services. This may include establishing paternity, establishing or modifying a support order for financial and medical support, and/or
enforcing the support order.
All services except medical support. Medical support means the non-custodial parent will provide health insurance, if available at a
reasonable cost.
Only services to establish paternity (legal fatherhood.) This will not provide you with child support or medical support services.
Only services to locate the non-custodial parent. This service will provide an address of the other parent only. It will not provide any child
support payments or medical support. The application fee of $25 must be paid before this service will be provided.
Idaho Child Support Services is authorized to endorse and negotiate payments related to child support and spousal support,
including checks, money orders, bank drafts, and electronic payments, on my behalf and on behalf of the children in my case.
I authorize Idaho Child Support Services to take legal and enforcement actions related to my case.
__________________________________________________________________________________________ ________________________________________________
Applicant’s Signature Date
CSS854 2/00
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