Application for Child Support Services - Indiana

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APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (continued)

Part of State Form 34882 (R11 / 12-13) / CSB 425A

TO BE COMPLETED BY COUNTY OFFICE

Application taken by: Date (month, day, year) Application request number

APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES - ASSIGNMENT FOR COLLECTION FOR PERSONS NOT RECEIVING PUBLIC ASSISTANCE

Name of applicant

AGREEMENT (TO BE COMPLETED BY THE APPLICANT)

I understand and agree that support payments collected hereafter from the non-custodial parent named above on behalf of myself and/or the above

named children will be paid to the Department of Child Services, Child Support Bureau, and that said support payments will be paid to me by the agency

after deduction of any charges due and owing to that agency. Such charges are explained on page one of the “Application for Title IV-D Child Support

Services”, executed by the applicant. This authorization shall continue in effect until terminated in the manner set forth on page one of the “Application for

Child Support Services”.

Printed name of applicant

Signature of applicant

Date signed (month, day, year)

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