Child Support Enforcement Form - Arkansas
Questionnaire and Application
R1015
Employer Address
City, State, Zip
Employer Phone Number
Race: ___Caucasian ___ African American ___ Hispanic ___ Asian
___ American Indian: Tribe ______________ ___ Other: ____________________
Are you or the children under an order of protection? ___Yes ___No
If yes, please provide a copy of the order.
Are you currently receiving the following services?
SSI: ___Yes ___No
SSA/SSD: ___Yes ___No
VA Benefits: ___ Yes ___ No
Worker’s Compensation: ___Yes ____No
Do you receive for yourself and/or the children listed any of the following?
TEA: ___Yes ___No If yes, provide your TEA case number _____________________
Medicaid, including the Arkansas Health Care Independence Program: ___Yes ___No
If yes, provide your case number _____________________
ARKids 1
st
A or B: ___Yes ___No If yes, provide the ARKids case number ________________
Have you ever in the past received cash public assistance (also known as TEA or TANF)? ___Yes ___No
If yes, please provide the state or tribal name(s) and the time frame during which assistance was received.
State or tribe: _________________________ Years of assistance: from _____ to _____
State or tribe: _________________________ Years of assistance: from _____ to _____
State or tribe: _________________________ Years of assistance: from _____ to _____
Do you have an attorney representing you on any matter related to the other parent? ___Yes ___No
If yes, please provide the following information about the attorney:
Name: _______________________________________________
Address: ______________________________________________
Phone number: _________________________________________
Information About The Children
Please provide the following information for each child for whom you are seeking services.
Child 1: Full legal name (first, middle, last) Date of birth Sex
Social Security number Race Place of birth (county & state)
Has a support order been established for this child? Was a Paternity Acknowledgment
completed?
Child 2: Full legal name (first, middle, last) Date of birth Sex
Social Security number Race Place of birth (county & state)
Has a support order been established for this child? Was a Paternity Acknowledgment
completed?
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