DIVISION OF CHILD SUPPORT ENFORCEMENT - APPLICATION INSTRUCTIONS: Please complete the entire application, attach all required documents, and sign before a Notary. (Notary services are provided free of charge at DCSE offices). Complete a separate application for each Non-custodial parent from whom you seek support. A $25.00 application fee is required (payable by check or money order) - unless you: (1) currently receive Medicaid, General Assistance, Food Stamps, or Child Care Subsidy, (2) have previously received federally funded Foster Care services, Temporary Aid to Needy Families (TANF), Medicaid, or (3) the child for whom you seek support is enrolled in a federal Head Start program. In addition, the Deficit Reduction Act of 2005 §454(6)(B), requires DCSE to charge an annual processing fee of $25 for each child support case in which the applicant has never received TANF assistance. DCSE will deduct this fee from child support payments to the custodial party after collections of at least $500 in each federal fiscal year (Oct. 1 – Sept. 30). PROCEDURES: DCSE will accept your application regardless of age, color, disability, ethnicity, gender, nationality, race, religion, or sexual orientation. DCSE will make every effort to establish paternity and child support orders in a timely manner through the Family Court of the State of Delaware. Your cooperation in providing all required information, as well as your involvement in this process, is necessary. DCSE utilizes all appropriate remedies to enforce child support orders including issuance of income withholding orders, interception of tax refunds, and license suspensions. Enforcement remedies are automatically activated according to case account status. DCSE will attempt to collect arrears owed to the state of Delaware until paid in full. OFFICE LOCATIONS and PHONE NUMBERS: New Castle County: Churchman’s Corporate Center 84-A Christiana Rd., New Castle, DE 19720 (302) 577-7171 Kent County: Carroll’s Plaza, Suite 101 9 Academy St., Dover, DE 19901 (302) 739-8299 Sussex County: 1114 S. DuPont Hwy. Georgetown, DE 19947 (302) 856-5386 Please submit your completed & Notarized application to your local DCSE office. In New Castle County, applications should be mailed to: P.O. Box 15012, Wilmington, DE 19850. WEBSITE www.dhss.delaware.gov/dcse DCSE USE ONLY: Date application requested:__________ Date application mailed:___________ Date application received: __________ NONDISCLOSURE OF INFORMATION (to protect address information): Is there a Protection From Abuse (PFA) order preventing the release of your address? ________ Yes ________ No If no, would the safety or liberty of you or your child(ren) be unreasonably put at risk by the release of your address or other identifying information? ________ Yes ________ No REQUIRED DOCUMENTS I understand that the verification of certain information is required in order for my case to be processed. I have provided or will provide copies of the documents listed below, if they are appropriate in my case. I understand that failure to provide copies of these documents will delay the processing of my case. I am attaching OR I will provide - Please check one of the boxes, for each line below. _____ ______ Birth Certificate for each child _____ ______ Acknowledgement of Paternity Form _____ ______ Original and modified support orders (including divorce decrees and custody orders). _____ ______ Orders established outside of Delaware must be certified by the Court in which they were established. _____ ______ Certified payment history/arrears statement, if order is established _____ ______ Copy of marriage license and divorce decree (if applicable) _____ ______ Copy of social security cards for each case member _____ ______ Protective order preventing release of address (if applicable) _____ ______ Copies of applicant’s three (3) most recent: Pay stubs or W-2 forms _____ ______ Copy of medical insurance card (both sides) Name: _______________________________________________________________________ (Last) (First) (Middle Initial) Address: ____________________________________________________________________ (Street) (City) (State) (Zip Code) Home Phone Number: _____________________________________ Cell Phone Number: _____________________________________ Date of Birth: ________________________________________ Maiden/Previous Name(s): _______________________________ Race: __________________________________________________ Sex: ______ Male or ______ Female Employer: ____________________________________________________________________ Work Phone Number: _____________________________________ Employer Address: ____________________________________________________________ 1. What is your relationship to the non-custodial parent? ____Never Married ____Currently Married ____Separated ____Divorced ____Other 2. If Married, Date of Marriage: _________________________________________ State & County Where Married: ________________________________________________ State of last shared address: _________________________________________________ 3. Date and Place of Divorce/Separation: _________________________________ Court: ________________________________________________________________________ County: _______________________________________________________________________ State: ________________________________________________________________________ 4. If separated, has a private attorney started divorce proceedings and/or is court action currently pending? _______ Yes ______ No If yes, please list name, address, and phone number of the Attorney and the County and State in which the court action is pending: Attorney: ______________________________________________________________________ Address: _______________________________________________________________________ Phone: _________________________________________________________________________ Court: _________________________________________________________________________ County: ________________________________________________________________________ State: _________________________________________________________________________ 5. Do you have a court order for child support already established? ______________ Yes or ______ ________ No If yes, please provide the Court, County, and State in which the order was established, along with a copy of the support order. Court: _________________________________________________________________________ County: ________________________________________________________________________ State: _________________________________________________________________________ 6. Have you ever received Temporary Assistance for Needy Families (TANF-formerly AFDC), State Medical Assistance, or previously applied for Child Support Services? ______ Yes ______ No. If yes indicate type of service, County and State: ______________________________________ 1. Child’s Name: ________________________________________________________________________ (Last) (First) (Middle) Date of Birth: _________________________________________________________________________ Social Security Number: ________________________________________________________________ Sex: ______ Male or ______ Female City & State of Conception: ___________________________________________________________ City & State of Birth: __________________________________________________________________ Race: __________________________________________________________________________________ Your relationship to the child: _________________________________________________________ Were the parents married to each other at the time of the child’s birth? ________ Yes ________ No If the parents were not married, is the father’s name is on the birth certificate. ________ Yes ________ No Was the mother married to anyone at the time of the child’s birth? ______ Yes ______ No If yes, indicate name of husband: _______________________________________________________ Date of Marriage: County & State: ______________________________________________________ If the parents were not married when the child was born: ________________________________ Has paternity been established for the child? ________ Yes ________ No Was genetic testing done? ________ Yes ________ No Was a “Voluntary Acknowledgement of Paternity” signed? ________ Yes ________ No If you answered yes to any of the above, indicate the date and in which County and State: _________________________________________________________________________________________ Is there an existing child support order for this child? ________ Yes ________ No If yes, amount $_____________Per ______________ Effective Date: _______________ Name of Court: _____________________________________________________________________ County & State: ____________________________________________________________________ Are the child’s parents divorced? ________ Yes ________ No If yes, date, County and State divorce order was entered: ____________________________________________________________________________________ 2. Child’s Name: _________________________________________________________________________ (Last) (First) (Middle) Date of Birth: _________________________________________________________________________ Social Security Number: ________________________________________________________________ Sex: ______ Male or ______ Female City & State of Conception: ___________________________________________________________ City & State of Birth: __________________________________________________________________ Race: __________________________________________________________________________________ Your relationship to the child: _________________________________________________________ Were the parents married to each other at the time of the child’s birth? ________ Yes ________ No If the parents were not married, is the father’s name is on the birth certificate. ________ Yes ________ No Was the mother married to anyone at the time of the child’s birth? ________ Yes ________ No If yes, indicate name of husband: _______________________________________________________ Date of Marriage: County & State: ______________________________________________________ If the parents were not married when the child was born: ________________________________ Has paternity been established for the child? ________ Yes ________ No Was genetic testing done? ________ Yes ________ No Was a “Voluntary Acknowledgement of Paternity” signed? ________ Yes ________ No If you answered yes to any of the above, indicate the date and in which County and State: _________________________________________________________________________________________ Is there an existing child support order for this child? ________ Yes ________ No If yes: Amount $_____________Per _____________ Effective Date: _______________ Name of Court: _____________________________________________________________________ County & State: ____________________________________________________________________ Are the child’s parents divorced? ________ Yes ________ No If yes, date, County and State divorce order was entered: ____________________________________________________________________________________ 3. Child’s Name: _________________________________________________________________________ (Last) (First) (Middle) Date of Birth: _________________________________________________________________________ Social Security Number: ________________________________________________________________ Sex: ______ Male or ______ Female City & State of Conception: ___________________________________________________________ City & State of Birth: __________________________________________________________________ Race: __________________________________________________________________________________ Your relationship to the child: _________________________________________________________ Were the parents married to each other at the time of the child’s birth? ________ Yes ________ No If the parents were not married, is the father’s name is on the birth certificate. ________ Yes ________ No Was the mother married to anyone at the time of the child’s birth? ________ Yes ________ No If yes, indicate name of husband: _______________________________________________________ Date of Marriage: County & State: ______________________________________________________ If the parents were not married when the child was born: ________________________________ Has paternity been established for the child? ________ Yes ________ No Was genetic testing done? ________ Yes ________ No Was a “Voluntary Acknowledgement of Paternity” signed? ________ Yes ________ No If you answered yes to any of the above, indicate the date and in which County and State: _________________________________________________________________________________________ Is there an existing child support order for this child? ________ Yes ________ No If yes: Amount $_____________Per________________ Effective Date: _______________ Name of Court: _____________________________________________________________________ County & State: ____________________________________________________________________ Are the child’s parents divorced? ________ Yes ________ No If yes, date, County and State divorce order was entered: ____________________________________________________________________________________ Do you or your child(ren) currently receive Medicaid? ________ Yes ________ No Do you have insurance available that covers the child(ren) for whom you are applying: ________ Yes ________ No Name of Health Insurance Company: __________________________________________________ Address of Insurance Company: ______________________________________________________ Policy#: ___________________________________________________________________________ Health Insurance Cost $_________ /Monthly Persons Covered:____________________________________________________________________ Name of Dental Insurance Company: __________________________________________________ Address of Dental Insurance Company: _______________________________________________ Policy#: Dental Insurance Cost$________/Monthly Persons Covered: ___________________________________________________________________ When a support order is entered or modified, DCSE must seek to ensure that one or both of the parents is/are responsible for providing health insurance (whether or not it is currently available) for the child(ren). Medical support will only be enforced against the parent responsible for the coverage if health insurance is determined to be available at a reasonable cost. Name: __________________________________________________________________________________ (Last) (First) (Middle) Social Security Number: ____________________________________________________________ Address: ____________________________________________________________________ (Street) (City) (State) (Zip Code) This address is either the: ______ Current OR ___________ the last known address Home Phone Number: _________________________________________________________ Cell Phone Number: _________________________________________________________ Date of Birth: ____________________________________________________________ City/State of birth: _______________________________________________________ Previous/Alias Name(s): ____________________________________________________ Race: Sex: _______ Male _______ Female Eye Color: _________________________________________________________________ Hair Color: ________________________________________________________________ Height: ____________________________________________________________________ Weight: ____________________________________________________________________ Employer: ___________________________________________________________________ Employer Phone Number: ____________________________________________________ Employer Address: __________________________________________________________ This employer is: ______ Current or Last known as of this date: _____________ Current, or prior, military service? ________ Yes ________ No If yes, branch: ____ Army ____ Navy ___ Air Force ___ Marines ____ Coast Guard Dates - from _________ to ___________ Has the non-custodial parent ever been in prison? ________ Yes ________ No If yes, date(s) of incarceration: __________________________________________ Name of Prison: ____________________________________________________________ Address: ___________________________________________________________________ Does the non-custodial parent receive a pension, disability benefits, social security, or have any other source of income? ________ Yes ________ No _________ Unknown If yes, indicate source: ___________________________________________________ Amount: $________per/__________ Does the non-custodial parent provide health insurance for the child(ren)? ________ Yes ________ No ________ Unknown If yes, name of Insurance Company: ___________________________________________________ Address of Insurance Company: ________________________________________________________ Policy Number: _____________________________________________________________ List any agency that has collected child support payments on behalf of your child(ren): ______________________________________________________________________________________ Address: _____________________________________________________________________________ (Street) (City) (State) (Zip Code) Phone Number: _________________________________________ Has the NCP ever made support payments directly to you? ________ Yes ________ No If yes, list only those payments paid directly below. Do not list payments received by an agency and forwarded to you according to the terms of the order. The information below is for the YEAR: ____________________ Amount Owed Balance Amount Paid Jan Jan Jan Feb Feb Feb Mar Mar Mar Apr Apr Apr May May May Jun Jun Jun Jul Jul Jul Aug Aug Aug Sept Sept Sept Oct Oct Oct Nov Nov Nov Dec Dec Dec Total Total Total Certification: I hereby certify that the statements I have given in this document are true and correct. I further agree to notify DCSE immediately of any changes in my address, telephone number, income, expenses, or employer. _____________________________________________________Signature ___________________Date Sworn and subscribed before me this ______ day of ________________________ 20____. Notary Public _______________________________________Signature ___________________Date By signing this document, I agree to the following: 1. I understand that, under Family Court Civil Rule 87.2, a petition for new support will be filed in the county where the child[ren] and I reside. I may submit to DCSE a written request to file in a different county. If I elect to file my support petition in a county other than where the child[ren] and I reside, I agree to absorb all expenses associated with attending the hearing(s), such as travel expenses, parking fees, and childcare costs. 2. I will appear at all mediation conferences and Family Court hearings held in Delaware. I understand that failure to appear in Family Court for scheduled hearings or mediations may result in dismissal of the petition and/or sanctions that could affect the receipt of state assistance. 3. I will cooperate with DCSE by providing requested documentation. 4. I understand that all child support payments must pass through the DCSE State Disbursement Unit for proper accounting. I understand that the Non-Custodial Parent may not receive credit for payments delivered to me directly, and I will report any direct payments I received to a DSCE worker. 5. I understand that DCSE will utilize all available resources to recoup or recover payments sent to me in error, including but not limited to, withholding future child support payments. 6. I understand that I am required to notify DCSE in writing within five (5) days of any of the following events: • If I retain the services of a private attorney. • If I have a change in name. • If I move or change my address. • If the custody of the child[ren] changes and I am no longer the primary custodian. 7. I agree to have DCSE act on my behalf to enter into negotiations with the Non-Custodial Parent or his/her attorney to settle any child support claims I may have. I further request DCSE to file any necessary legal documents against the Non-Custodial Parent. Under Delaware law, a Deputy Attorney General who handles my case is deemed to represent the state agency, DCSE, and not me individually. 8. I will comply with DCSE requirements and administrative enforcements to effectively process my case these services are available to me under the Child Support Enforcement Program: • Locate parent(s) responsible to provide support y Establish paternity • Enforce support order • Establish medical (health insurance) order • Modify existing order • Establish child support order Services will be implemented in accordance with my case status. I can stop services by notifying DCSE in writing. 9. Notice Regarding Use of Social Security Numbers (SSN): Federal child support mandates [42 USC §666(a)(13)] require the collection of SSNs for all individuals involved in paternity and child support orders. SSNs are used under the state’s child support enforcement program to locate individuals for purposes of establishing paternity and establishing, modifying and enforcing support obligations. Signature of Applicant__________________________________________ Date _____________ Sworn and subscribed before me this ______ day of ________________________ 20____. Notary Public Signature _______________________________________ Date _____________ Copy to Custodial Party.