Custodial Parent IV-D Application

CUSTODIAL PARENT APPLICATION FOR IV-D SERVICES
Please complete and sign the application. There is no cost to apply for services. You will pay a $35 fee each year that you receive more than $550 in child support collections. The fee will be automatically deducted from the child support payment. Current and former TANF and Foster Care cases are exempt from this fee.
Important Safety Information
(Please Print All Information) If you have concerns regarding family violence, there are some protections available in the child support process. The following questions will provide relevant information to determine the actions necessary for your case. You may wish to visit www.texasattorneygeneral.gov/child-support to find out about the protections available in the child support process.
Have you or your child(ren) experienced the following by the other parent?
Physical abuse
Emotional abuse
Threats
Harassment
Serious harm or Injury
Will opening a child support case pose a family violence risk for you and/or your child(ren) with the other parent?

Yes No
Will opening a child support case pose a family violence risk for you and/or your child(ren) with someone other than parent of your child(ren)?

Yes No
If you selected YES, please provide the name of the other person and describe the relationship you/ or your child(ren):
Do you have a protective order, police report, or other supporting document?

Yes No
If possible attach a copy of any documentation.

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In certain circumstances, a court can order that information related to your place of residence or contact information be excluded from the court order. Would requiring you to provide residence or contact information to the other parent or another party cause you or your child(ren) harassment, abuse, serious harm, or injury

Yes No
My Name:

First Name Last Name
Date of birth:
SSN:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email: *
example@example.com
My relationship to child(ren):
If you are under the age of 18 years and are not married or emancipated, please list your parent or guardian’s name and contact information.
Name of parent/ guardian:
Phone number:
Please enter a valid phone number.
Check this box if you do not have a parent or guardian who can serve as your adult representative.
Check this box if you are under 18 years of age and your are married, you have joined the military, or the court has declared you emancipated.
The person responsible for paying child support is
Name:

First Name Last Name
Date of birth:
SSN:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to the child(ren)

Father Mother Other
What is the current relationship between the mother and the biological father of the children?

Never married Divorced Married
Date of the Marriage Ceremony Date County: County St: State
If you are divorced or have any court order (divorce order, paternity order, custody order, protective order, etc.) of any kind regarding the child(ren) please attach a copy of the order to this form.
File Upload for available copies of orders

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If you are unable to provide a copy you must provide the following
Date: Date Cause/Case Number: County County: County State: State Court: State
List the child(ren) and the dates of birth for whom this person is, or may be responsible:
First NameFirst Name Last Name: Last Name Date of Birth:Date
First NameFirst Name Last Name: Last Name Date of Birth:Date
First NameFirst Name Last Name: Last Name Date of Birth:Date
First NameFirst Name Last Name: Last Name Date of Birth:Date
First NameFirst Name Last Name: Last Name Date of Birth:Date
First NameFirst Name Last Name: Last Name Date of Birth:Date
If this application relates to more than six children, provide the names and dates of birth on a separate page for any additional children.
File Upload for Additional Children if needed

Cancel of
Texas Government Code Chapter 559 gives you the right to review and request correction of information on this form.

I request all appropriate IV-D servicesof the Office of the Attorney General, Child Support Division. The information in this application is trueand complete. I have either read theattached information, or had it read to me. My signature is my agreement to the above statement and to the otherstatements included in this application packet.
Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

CUSTODIAL PARENT APPLICATION FOR IV-D SERVICES

Important Safety Information

Have you or your child(ren) experienced the following by the other parent?

The person responsible for paying child support is

If you are divorced or have any court order (divorce order, paternity order, custody order, protective order, etc.) of any kind regarding the child(ren) please attach a copy of the order to this form.

If you are unable to provide a copy you must provide the following

List the child(ren) and the dates of birth for whom this person is, or may be responsible:

If this application relates to more than six children, provide the names and dates of birth on a separate page for any additional children.

Texas Government Code Chapter 559 gives you the right to review and request correction of information on this form.