INDIANA CHILD SUPPORT SERVICES ENROLLMENT

OTHER PARENT INFORMATION
Last Name
First Name
Middle Name
Suffix
Does this parent have primary physical custody of dependents on this form?

YesNo
Date of birth (month, day, year)

MonthDayYear
Date
Other names used
Gender
Race
Relationship to dependents on this form (mother, father, potential father, guardian, other)
Height
Weight
Hair Color
Social Security Number / ITIN
Other distinguishing characteristics eye color, tattoos, etc
Home address (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Mailing address, if different from address above (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Does this parent need special assistance?

YesNo
Telephone number (cellular)

Country CodeArea CodePhone Number
Telephone number (home)

Country CodeArea CodePhone Number
Telephone number (work)

Country CodeArea CodePhone Number
Do either of the following apply?

Active Military DutyCurrently Incarcerated
E-mail address
example@example.com
Specify assistance needed here (physical, hearing impaired, language interpreter, other)
Current or last known employer
Specific assistance needed here (physical, hearing impaired, language, interpreter, other)
Employer telephone number
Address of employer (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Does this parent have a private attorney handling paternity and/or support matters for dependents listed in this form?

YesNo
Name of attorney (full name)

AFFIRMATION AND AGREEMENT
- I hereby swear and affirm under the penalties of perjury that the information contained in this for is true and correct to the best of my knowledge. Providing false information could result in perjury charges being filed against me.
- I understand that child support services DO NOT include establishment or enforcement of parenting time or parenting time credits, the assignment of the right to claim a child as a dependent for federal or state tax purposes, nor any matters other than those associated with establishment of paternity (if needed) and the financial support of dependent children.
- I am advised that attorneys and staff at the Child Support Bureau and County Child Support Office providing these child support services represent the State of Indiana and do not represent the enrollee or any other person or entity. Communications between the enrollee or other participants and the Child Support Bureau or County Child Support Office are not confidential communications protected by the attorney/client privilege under IC 34-46-3-1.
- I understand that I must cooperate with the County Child Support Office in order for my case to be processed, and non- cooperation can result in termination of child support services. I further understand that this enrollment to receive child support services does not guarantee successful action on the case but rather that all reasonable attempts will be made to obtain successful results. I understand that I may terminate services by notifying the County Child Support Office handling my case in writing that services are no longer desired. Services may only be terminated in accordance with 45 C.F.R. 303.11. Termination of these services does not modify or terminate existing child support orders or obligations.
- I authorize the Indiana State Central Collection Unit (INSCCU) to endorse and negotiate any checks received by INSCCU for payment of support on my child support case.
I hereby swear and affirm under the penalties of perjury that the information contained in this form is true and correct to the best of
Printed name of parent / guardian (if enrollee is an unemancipated minor)
I agree that if I am overpaid, the state my recoup the amount of the overpayment from future child support payments owed to me.

YesNo
Printed name of enrollee
Date signed (month, day, year)
Signature of parent/guardian (if enrollee is an unemancipated minor)

Clear
Signature of enrollee

Clear
Should be Empty:

INDIANA CHILD SUPPORT SERVICES ENROLLMENT

NOTICE TO ENROLLEE

ENROLLEE INFORMATION

DEPENDENT #1 INFORMATION

DEPENDENT #2 INFORMATION

DEPENDENT #3 INFORMATION

OTHER PARENT INFORMATION

AFFIRMATION AND AGREEMENT