Child Support Enforcement Form - Arkansas
Questionnaire and Application
R1015
Office of Child
Support Enforcement
Questionnaire
This Questionnaire is necessary in order to provide child support services. Fill out the questionnaire
completely. The more information we have, the better we are able to help you.
The disclosure of your Social Security number is mandated by Public Law 104-193 in order that the
Office of Child Support Enforcement (OCSE) may provide services related to the establishment of
paternity and the establishment, modification, and enforcement of child and/or medical support
obligations.
If you receive TEA or Medicaid benefits for yourself, including the Arkansas Health Care Independence
Program (also called the Private Option), complete and return only this questionnaire. All other persons
seeking child support enforcement services must return both this Questionnaire and the Contract for
Services. A $25.00 application fee is required from all applicants except those who receive TEA benefits,
Medicaid, including the Arkansas Health Care Independence Program, or whose child is receiving
ARKids 1st A or B. You may return these forms to the local child support office nearest you or mail it to
OCSE, P.O. Box 8133, Little Rock, AR 72203.
Be sure to attach the following:
• Copies of the original child support order, if there was one, and any modified (changed) orders. Also
include copies of any guardianship or custody orders, juvenile orders, temporary orders, probate
orders, or orders of adoption.
• Payment records from the clerk of court or a child support agency in another state.
• Copies of the child’s or children’s birth certificates and an Acknowledgement of Paternity, if one was
signed.
• If you are enrolled in Medicaid or your child is receiving ARKids 1st A or B, provide a copy of your
Medicaid or ARKids card. If you are enrolled in the Arkansas Health Care Independence Program,
provide a copy of your DHS acceptance letter.
Office Use Only
Date Requested: _______________________________
Date Provided: ________________________________
Fee Paid: ________ Date Received: ______________
Receipt #: _______ Case ID: ____________________
Information About You
Name
Physical Address
City, State, Zip
Mailing Address
City, State, Zip
Phone Home Work Cell
Email
Social Security Number Date of Birth
Employer Name
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You can complete this form by
hand or online. Once complete,
print the form, sign where
required, and submit to the
appropriate child support office.
Page 1/7
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