Application for Child Support Services - Indiana

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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES
State Form 34882 (R12 / 1-14) / CSB 425A
Approved by State Board of Accounts, 2014
PRIVACY STATEMENT
*The records in this series are confidential
according to 42 USC 653, 42 USC 654, and 42
USC 663. This agency is requesting disclosure
of personal information for agency purposes as
required by these statutes. Disclosure of this
information is mandatory. Failure to provide
any information may prevent this form from
being processed.
INSTRUCTIONS:
1. Take or mail this completed form to your local county Prosecutor’s IV-D Child Support Office.
2. If multiple other parents, complete one application for each.
NOTICE (please read)
The Indiana Child Support Bureau offers child support services to persons desiring to obtain child support from a parent outside the
home. These services are: Complete Service or Parent Locator Service Only. ALL FEES FOR SERVICES ARE NONREFUNDABLE.
COMPLETE SERVICE: The applicant will be entitled to the Parent Locator Service and the services of the local county Prosecutor’s IV-
D Child Support Office. These services include Establishing Paternity, Establishing and/or Enforcing a support obligation (including
health insurance coverage). The complete service does NOT include handling a divorce case, enforcement of custody or parenting time,
nor matters other than those associated with the support of dependent children. All support payments must be directed to the State of
Indiana for disbursement. ANY COSTS INCURRED IN EXCESS OF THE APPLICATION FEE, SUCH AS COURT COSTS, WITNESS
FEES, GENETIC TEST COSTS, IRS OFFSET FEES AND ADMINISTRATIVE COSTS ASSOCIATED WITH THIS CASE MAY BE
CHARGED AGAINST THE APPLICANT.
In addition, the Tax Refund Offset Project may be used to collect child support arrearages. Application for complete service does not
guarantee that your case will be submitted for tax refund offset nor that tax refund monies will be collected. If any children of the non-
custodial parent have received TANF in the past, any collection made from an offset will first be applied to any unreimbursed public
assistance on any former or current TANF case. If the IRS recalls any portion of an offset refund that has already been paid to you, you
are obligated to repay the State of Indiana the amount recalled by the IRS. You authorize that any such repayment may be deducted
from support collected on your behalf if other arrangements have not been fulfilled.
PARENT LOCATOR SERVICE ONLY: The applicant will be entitled to resources offered by the State and Federal Parent Locator
Service until a verified address is provided or all sources for location are exhausted. The payment of the application fee does not
guarantee a successful location.
TERMINATION OF SERVICES: The applicant may terminate services (if fees, costs and any child support overpayments have been
paid in full) by notifying the local county Prosecutor’s IV-D Child Support Office handling your case in writing that services are no longer
desired. Services may be terminated only in accordance with 45 C.F.R. 303.11.
APPLICANT'S OBLIGATIONS: The applicant is expected to fully cooperate with the local county Prosecutor’s IV-D Child Support Office
in the legal and non-legal preparation of the case, including, but not limited to notifying the local county Prosecutor’s IV-D Child Support
Office of change of address, supplemental information regarding the other parent, reuniting with the other parent, and other information
pertinent to the case.
APPLICANT'S AFFIRMATION
I hereby swear and affirm under the penalties of perjury that the information contained in this application is true and correct to the best of
my knowledge and providing false information could result in perjury charges being filed against me.
I understand that I am to cooperate with the local county Prosecutor’s IV-D Child Support Office in order for my case to be processed, and
non-cooperation can result in termination of services offered by the IV-D agency. I further understand that payment of the application fee
does not guarantee successful action on the case but rather all reasonable attempts will be made in my behalf to obtain successful results
for the service requested. I have read and understand the above NOTICE.
I hereby request the following service under the terms outlined above:
Complete Service Parent Locator Service Only
Type of Services Requested:
Paternity Establishment Support Establishment Support Modification Establishment/Enforcement Health Insurance
Signature of applicant
Date signed (month, day, year)
Application taken by:
Fee paid
$
Case number
FOR OFFICIAL USE ONLY:
Case Type Assigned County of Ownership Special Handling
Applicant Other Parent
Notes/Description
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