The information requested in this questionnaire is needed for the Office of Child Support Enforcement (OCSE) to provide child and medical support services to you. You may be asked to update this information from time to time. The more information we have, the better we are able to help you.

You may return this questionnaire and the items listed blow to the child support office nearest you or mail it to OCSE, P.O. Box 8133, Little Rock, AR 72203.

You may also apply for child support services online. Go to www.childsupport.arkansas.gov and click the "Apply for Services" button.

Along with the questionnaire, return the following:

• A $25 non-refundable application fee. EXCEPTION: Fees are not charged to Medicaid recipients. Do not include the $25 application fee if you receive Medicaid, including ARHOME, or if the child for whom you are requesting services is receiving ARKids 1st A or B.

• 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, if applicable.

• Copies of birth certificates for the children for whom you are seeking services.

• If the biological parents were not married at the time of the child's birth, a copy of an Acknowledgment of Paternity, if one was signed.

The disclosure of your Social Security number is mandated by Public Law 104-193 so that OCSE may provide services related to the establishment of paternity and the establishment, modification, and enforcement of child and/or medical support obligations.

In many cases, OCSE can take steps to help you receive child support services safely. Please explain your concerns and include information about any police reports or orders of protection you may have.

Child 1: Full legal name (first, middle, last)

Child 2: Full legal name (first, middle, last) Only list the child if they have the same absent parent as the first child listed. A new form must be completed for every child that has a different ansent parent

Child 3: Full legal name (first, middle, last)

Child 4: Full legal name (first, middle, last)

Child 5: Full legal name (first, middle, last)

If no, Arkansas law provides that you may receive back child support for up to three years before legal action is filed in your case. Factors such as the age of the child and if the other parent has lived with or supported the child in other ways will affect if back support is available and the time periods it may be ordered.

If you are not the biological parent of the child or children for whom you are requesting service, please answer the following:

Please provide as much information as possible about the other parent. If you don't have the information now but find it later, you can update this information.

**NOTE: This Application and Contract for Services must be signed and included with the Questionnaire. EXCEPTION: If you, the custodial party, are a recipient of Medicaid (including ARHOME) submit the Questionnaire, but you are not required to sign this Application and Contract for Services.**

The applicant agrees:

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 adequately 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 interest 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 ARHOME.

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 Assistance (TEA) grant which the applicant received prior to this Contract. Should this contract be canceled 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 reference. 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 additional 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 pursuant to the cost schedule that was provided to the applicant with this Application and Contract for Services but not previously imposed due to their participation in ARKids 1st.

11. Understands the agency will disburse support payments electronically to a prepaid debit card unless the applicant requests payment to be made by direct deposit or is granted an exemption.

12. Acknowledges that if situations occur where money is received to which the applicant is not entitled, the money must be returned voluntarily to OCSE, or, as required by Arkansas law, OCSE will take the appropriate actions necessary to recover that money. Any decision made regarding the method of recovery of the money will not preclude or affect child support services being provided to you by OCSE.