Child Support Enforcement Form - Arkansas
Questionnaire and Application
R1015
*** NOTICE ***
IF YOU ARE A RECIPIENT OF CASH ASSISTANCE, SUCH AS TEA, OR RECEIVE
MEDICAID, INCLUDING THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM
(ALSO CALLED THE PRIVATE OPTION) FOR YOURSELF, DO NOT SIGN THIS
APPLICATION AND CONTRACT FOR CHILD SUPPORT SERVICES
Application and Contract for Child Support Services
The applicant hereby and herein:
1. Authorizes the agency to assign legal counsel of its choice to act on behalf of the agency and
applicant’s assigned interest, and be the attorney of record for the agency to establish paternity
and/or a monthly support obligation, and to enforce payment of such obligation. The attorney
does not represent the applicant. There is no attorney/client relationship created between the
applicant and the attorney.
2. Understands that the OCSE attorney represents the State’s interest in having children ad-
equately supported and in collecting overdue support. The applicant retains the right to employ
separate private counsel.
3. Agrees that the agency shall have the right to collect from the noncustodial party both current
and past due support payments in the amount provided by the support order.
4. Agrees that the agency, rather than the applicant, shall have any and all rights, title and inter-
est in any and all property belonging to the noncustodial parent against which a claim may be
placed for the collection of child/spousal support.
5. Agrees to forward to OCSE any and all support payments which he or she receives directly
from the noncustodial parent after the date of acceptance of this Application and Contract.
6. Agrees to notify OCSE of any changes in the applicant’s address.
7. Agrees to notify OCSE of any Court action which may change or affect the support order.
8. Agrees to notify OCSE of changes to medical coverage, such as participation in ARKids 1st or
Medicaid, including the Arkansas Health Care Independence Program.
9. Agrees that the agency retains all rights to enforce and collect child support arrearages and
child support judgments in an amount equal to any unreimbursed Transitional Employment As-
sistance (TEA) grant which the applicant received prior to this Contract. Should this contract be
cancelled or terminated, the applicant understands and agrees that OCSE will continue to pursue
the collection of TEA grant through IRS tax intercept until the debt owed to the State is satisfied.
10. Agrees to pay all costs and fees charged for child support enforcement services pursuant to
the Cost Schedule except while participating in ARKids 1st A or B or if receiving public benefits
such as TEA or Medicaid in the future. A copy of the cost schedule for services was provided to
the applicant with this Application and Contract for Services and is incorporated herein by refer-
ence. The applicant understands costs and fees will be deducted from support collected at a rate
not to exceed 13% of the total amount collected or the actual fees and costs due, whichever is
less. The applicant understands that in interstate cases the responding state may charge addi-
tional costs. The applicant further understands that if enrollment in ARKids 1st A or B ceases, the
applicant agrees to pay all costs and fees charged for child support enforcement services pursu-
ant to the cost Schedule for Services that was provided to the applicant with this Application and
Contract for Services but not previously imposed due to their participation in ARKids 1st A or B.
11. Understands the agency will disburse support payments electronically to a prepaid debit card
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