Montgomery County CSEA Application for Child Support Services

APPLICATION FOR CHILD SUPPORT SERVICES
I request child support services from the Montgomery CSEA (Child Support Enforcement Agency.
I understand and agree to the following:

A. I am a resident of the county in which services are requested and no other Ohio county has jurisdiction over support - OR am requesting services from the Ohio county of jurisdiction.

B. The only fee that can be charged for services is a one-dollar application fee. Some counties pay this fee for the applicants. Montgomery County does not collect this fee.

C. Recipients of child support services shall cooperate to the best of their ability with the CSEA. (See attached rights and responsibilities information

D. In providing IV-D services, the CSEA and any of its contracted agents (e.g., prosecutors, attorneys, hearing officers, etc represent the best interest of the children of the state of Ohio and do not represent any IV-D recipient or the IV-D recipient's personal interest.

The Child Support Enforcement Agency can assist you in providing the following services:

1. Location of Non-custodial Parents. The agency can assist in finding where a non-custodial parent is currently living, in what city, town, or state. The applicant can request 'Location Only Services', if the sole need is to find the whereabouts of the non-custodial parent.

2. Establishment or Adjustment of Child Support and Medical Support. The CSEA can assist you to obtain an order for support if you are separated, have been deserted, or need to establish paternity (fatherhood The CSEA can also assist you in changing the amount of support orders (adjustment), and to establish a medical support order.

3. Enforcement of Existing Orders. The CSEA can help you collect current and past-due child support.

4. Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages. The agency can collect past-due support (arrearages) by intercepting a payor's federal and state income tax refunds in some cases.

5. Withholding of Wages and Unearned Income for the Payment of Court Ordered Support. The agency can help you get payroll deductions for current and past-due child support and can intercept unemployment compensation to collect child support.

6. Establishment of Paternity. The agency can obtain an order for the establishment of paternity (fatherhood), if you were not married to the father of the child. An absent parent may request paternity services.

7. Collection and Disbursement of Payments. The CSEA can collect the child support for you and send you a check for the amount of the payments received. Past due support collected will be paid to you until all of the past-due support you are owed is paid.

8. Interstate Collection of Child Support. The agency can assist you in collecting support if the payor is living in another state or in some foreign countries.
**A separate application is needed for each father (or possible father)**

Please provide the name, date, location, and current status for EACH of your marriages, divorces, or separations:
Name of Spouse #1
Place of Marriage
AND Date of Marriage

MonthDayYear
Date
Are you divorced/separated? If yes, date of divorce/separation

MonthDayYear
Date
AND place of divorce
Have you been married to anyone else?

YesNo

Name of Spouse #2
Place of Marriage
AND Date of Marriage

MonthDayYear
Date
Are you divorced/separated? If yes, date of divorce/separation

MonthDayYear
Date
AND place of divorce
Have you been married to anyone else?

YesNo

Name of Spouse #3
Place of Marriage
AND Date of Marriage

MonthDayYear
Date
Are you divorced/separated? If yes, date of divorce/separation

MonthDayYear
Date
AND place of divorce
If divorce is pending, please provide:
Attorney's Name
Attorney's Phone #

Types of Service(s) requested:

All Services ListedLocation of Absent Parent OnlyOther
If other, please explain:
Copies of your child(s) birth certificate(s) are required to be submitted with your application.

To better service your case timely please attach copies of all marriage licenses, copies of all divorce decrees, and any custody orders regarding the child/children.

I hereby indicate that these answers are full and correct to the best of my knowledge and belief. I understand that under Ohio law any rights I have in and to support for myself or minor children under current court order is assigned to the state of Ohio for such period/periods during which public assistance is given.

I understand that the Child Support Agency within 20 days of receiving this application will contact me by a written notice to inform me if my case has been accepted for child support services (IV-D Services
Signature of Applicant (or legal custodian if a minor)*

Clear
Print Name*
Date*

MonthDayYear
Date
Minor Parent's Signature

Clear
Print Name
Date

MonthDayYear
Date
Birth Certificates:*

Please attach the birth certificate for each child.
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Other Documentation:

Ex: Marriage licenses, divorce decrees and any custody orders regarding the child(ren).
Cancelof

APPENDIX 1-24

RIGHTS AND RESPONSIBILITIES OF PARENTS

RECEIVING CHILD SUPPORT SERVICES

Confidentiality of Case Material Information

· You have the right to see the parts of your file at the Child Support Enforcement Agency (CSEA) about you and action taken for you by the agency.

· You cannot see some parts of your file that are protected by confidentiality laws, such as information obtained from the IRS.

· Information about you in the CSEA file is confidential. However, certain portions of your file become public record when a court is notified about your case.

Hearing Rights
If you disagree with any action, lack of action or delay by the CSEA, you can ask for a state hearing. For a full explanation of your hearing rights and the hearing process, please read the attached JFS 04059, Explanation of State Hearing Procedures.

OWF Participants
· As a condition of eligibility to receive OWF benefits, you give up the right to keep child and spousal support up to the amount of assistance you received.

· You must cooperate in establishing paternity for each child born, if you were not married to the father.

· You must assist the agency in getting support payments and any other payments.

· If you fail to cooperate without good cause (determined by your CSEA) you may be ineligible to receive OWF benefits.

While a family is receiving OWF, support collections are used to repay benefits. When a family leaves OWF, current support and family arrears are released to the family. Payments from the Internal Revenue Service (IRS) are applied to repay benefits before being applied to support payable to the household.

Medicaid Participants
While Medicaid benefits are received, cash medical support is paid to ODJFS to reimburse Medicaid benefits. If health insurance is available, that insurance will be used first for payment of medical bills. If you are eligible for medical assistance and are covered by a health insurance plan, it is your responsibility to notify the physician, hospital or other provider of medical services that you have medical insurance coverage and Medicaid coverage for the uninsured costs.

IV-E Foster Care Participants
If a child receives Title IV-E foster care benefits, the assignment includes current child support during the time the child is eligible for benefits and child support arrearages accruing before and during the time the child is eligible for benefits. Support that does not exceed foster care maintenance payments is distributed reimburse Title lV-E benefits. When IV foster care maintenance benefits cease, the assignment of support rights terminates, except for the amount of any unpaid support that accrued under the assignment.

The CSEA Can Assist You with the Following Available Services:
1. Location of Absent Parent(s), including "Location Only Services" if the sole need is to find the absent parent.

2. Establishment or Adjustment of Child Support and Medical Support, if you are separated, have been deserted or need to establish Paternity. The CSEA can help with a Review and Adjustment of your support order (if timely) and help establish a medical support order.

3. Enforcement of Existing Orders, to help you get current support and back child support.

4. Federal and State Income Tax Refund Offset, by intercepting a non-payor's federal and state tax refunds

5. Withholding of Various Types of Income, to help you get payroll deductions for current and back support

6. Establishing Paternity, by obtaining an order for paternity establishment, if you were not married to the father of the child. An absent parent may also request paternity services.

7. Collection and Disbursement of Payments, and send you a check for the amount of payments received.

8. Interstate Collection of Support, can assist you if the payor is living in another state or in some foreign countries.

Review and Adjustment of Child Support Orders
Each party to the support order has a right to request a review for adjustment of the order thirty-six (36) months from the establishment of the order or from the date of the most recent review, or sooner, if certain circumstances are met. Contact the CSEA for further details.

Fees
· There is an application fee of one dollar for applicants not receiving OWF, Medicaid, or IV-E foster care benefits. The application fee may be absorbed by the CSEA.

· There is no charge to recipients of OWF, Medicaid, and IV-E foster care.

Child Support Overpayments
An overpayment is child support that you are not entitled to keep because:

· You have assigned (transferred) your rights to support to ODJFS.

· The payment was made to you instead of ODJFS.

· The payment was sent to you in error by ODJFS.
I understand that I am personally liable for returning any amounts paid to me in error, including amounts that must be returned because IRS or ODT accepts an amended tax return or complaint from the non-obligated spouse. I also understand, that in refund situations, I may be required to sign an affidavit attesting to the amount of support arrears.*

Clear
Date*

MonthDayYear
Date
Should be Empty: