MADISON COUNTY CHILD SUPPORT SERVICES	DATE: 
15 BRIDGE ST
PO BOX 339
MARSHALL, NC 28753

CHILD SUPPORT SERVICES APPLICATION

APPLICANT NAME: APPLICANT ADDRESS:
CITY:
STATE:                     ZIP:

Dear APPLICANT FIRST LAST NAME,

Thank you for your interest in the North Carolina Child Support Services (NCCSS) program. Child support services are available to all applicants: parent, alleged fathers, non-parent caretakers, minor children, social services agencies and judicial officials. If you decide to apply for child support services, please complete the application in its entirety and sign where appropriate.

To help us process your application as quickly as possible, please return the following:
•	The application (filled out completely, to the best of your ability)
•	Proof of your income, if you are the child(ren)’s parent (e.g. pay stubs, tax returns, etc.)
•	Copy of your Photo ID (e.g. driver’s license)
•	Copy of each child’s state-issued birth certificate and Social Security card
•	Photo of the child’s other parent (noncustodial parent from whom child support services are being requested)
•	Copy of marriage certificates; if not available, provide dates of marriage and/or other verification of marital status of the children’s parents
•	Copy of any legal documents related to the child(ren) included in this application, such as:
o	Affidavit of Parentage - a legal document signed voluntarily by both parents (either in the hospital or at any time after the birth of the child) that establishes paternity
o	Paternity order (court order establishing paternity)
o	Child support and/or spousal support order(s) (all initial and modified orders)
o	Agreement signed voluntarily by the parents for child support
o	Copy of the child(ren)’s parent’s marriage and/or divorce decree
o	Order(s) terminating parental rights
o	Domestic violence protective order(s)
•	Payment records of all support paid directly to the custodial parent or through a court
Mail or take your completed application and applicable documents, along with your non-refundable $25 application fee, to the child support agency. The application fee must be a certified check or money order made payable to the specific county that you are requesting to handle your support case (e.g. “Wake County Child Support Services”). Some local child support agencies may also accept cash payment when applying in person. If your income is below 100 percent of the Federal Poverty Guidelines, you may qualify for a reduced non-refundable $10 application fee. Please contact the child support agency if you need assistance determining if you qualify for a reduced application fee.

If you need additional information or assistance in completing the form, you may contact the local child support agency or call the NCCSS Customer Service Center at 1-800-992-9457.

Respectfully,

BRITTANY HAMLIN 
AGENCY DIRECTOR
(828) 649-3820

To start the child support services process, please complete the following steps:

Step 1:
•	Read the North Carolina Child Support Services (NCCSS) services, policies, applicant rights and responsibilities, and Sign and Date (p. 3-5)
Step 2:
•	Complete Section 1 – Applicant/Public Assistance Recipient Information
o	You MUST select the appropriate information boxes, and Sign and Date
o	If you are a minor child applicant requesting child support services from your own parents, fill out Section 1 and all other sections except Section 3
Step 3:
•	Complete Section 2 – Custodial Parent/Guardian Information
Provide the caretaker of the child(ren)’s information
o	If you are the noncustodial parent applying for service, provide the caretaker of the child(ren)’s information
o	ONLY complete the income section if your relationship is “mother” “father” “alleged father” or “self”
to the child(ren) for whom you are requesting services
Step 4:
•	Complete Section 3 – Minor Child Information
Complete for each child for whom child support services are being requested
o	If you are applying for child support services for more than two children, please complete an additional Section 3 for each additional child and attach it to the application. You can get additional copies of Section 3 from the child support website (www.ncchildsupport.com), or by calling the NCCSS Customer Service Center at (800) 992–9457 or your local child support agency
o	Minor child applicants may skip this section and go to Section 4
Step 5:
•	Complete Section 4 – Noncustodial Parent Information
o	Provide information about the noncustodial parent(s) from whom child support services are being requested. If the application is for more than two noncustodial parents, please complete an additional Section 4 for each additional noncustodial parent and attach it to the application. You can get additional copies of Section 4 from the child support website (www.ncchildsupport.com), or by calling the NCCSS Customer Service Center at (800) 992–9457 or your local child support agency
Step 6:
•	Complete Section 5 – Attachments
Check each item that you are attaching to the completed application
o	If an item being attached is not one of the options, please check the option “Other” and write the item description
Step 7:
•	Complete Section 6 – Other Information
List any information that has not been provided in the application that may assist the child support agency in processing your application
Step 8:
•	Complete Section 7 – Certification Statement
o	You MUST Sign and Date
Step 9:
•	Detach and keep the “APPLICANT COPY” for your records (p. 23-24)
•	

FOR AGENCY USE
Date Application Requested:  	 Date Application Mailed:         	  Date Application Received:    		 Services: Child Support      Medical Support Locate Only           
IV-D #  	
NPA 	TANF          _ MAO 	FC 	
Fee paid by: CP 	NCP  	
Amt. $ 	Cash 	Money Order	
Certified Check 			

North Carolina
Department of Health & Human Services Division of Social Services
Child Support Services 1-800-992-9457 Toll Free

APPLICATION FOR SERVICES

North Carolina Child Support Services (NCCSS) administers the North Carolina child support program under Title IV-D of the Social Security Act. Services are available to a parent, alleged fathers, non-parent caretakers, minor children, social services agencies and judicial officials. The child support program’s goal is to provide the best possible services to families for children. Whether you are making an application for child support services as a recipient of assistance from other social services programs (Temporary Assistance to Needy Families [TANF], Foster Care and/or Medicaid) or requesting child support services as a non-public assistance applicant, your involvement, information, and contributions are important and required.

NORTH CAROLINA CHILD SUPPORT SERVICES INFORMATION

PROGRAM SERVICES
NCCSS provide child support services to assist families in meeting their financial obligations for children. There is no residency or citizenship eligibility requirement for services. Depending on the circumstances of each family, one or more of the following services may be appropriate:
•	Location of noncustodial parent – State, federal, local and national resources are used to assist in collecting information about a parent, such as their residence, employment and/or financial assets.
•	Paternity establishment – A determination of parental legal responsibility for the child(ren) is necessary before a parent can be required to pay support. If a child’s parents were not married to each other at the time of the child’s birth, arrangement of paternity testing may be offered to the parties, if appropriate.
•	Support establishment – In North Carolina, support is determined using the guidelines established in state law.
N.C. Child Support Guidelines consider both parent’s monthly gross incomes, the amount of time the child spends with each parent and various expenses. NCCSS seeks to establish a court order requiring a parent to provide child and/or medical support for child(ren) based on the N.C. Child Support Guidelines.
•	Collection of support – Child support payments through bank draft, money order, or check are sent to N.C. Child Support Centralized Collection (NCCSCC). A large amount of child support payments is deducted from a parent’s wages and sent to NCCSCC by an employer. North Carolina Child Support Services records and disburses all collected child support payments to families by personal direct deposit into a bank account or debit card.
•	Enforcement of support – Enforcement of an established or existing child support, spousal support, and/or medical support court order is met by wage withholding, tax refund offset, liens, professional license/passport revocation, credit reporting, court action or other collection remedies. Support orders may be reviewed for modification (increase/decrease) every three years or more often, if warranted.
NCCSS does not provide the following services: custody, visitation or the establishment of spousal support obligations.
PROGRAM FEES
•	Application Fee – Families receiving public assistance (TANF, Medicaid and/or Foster Care) are not charged an application fee for support services. Families that are not receiving public assistance are charged a non- refundable application fee of up to $25. If the applicant’s income is below 100 percent of the Federal Poverty Guidelines, a reduced application fee of $10 is available. Contact your local child support agency for additional information about qualifying for the reduced application fee. The application fee must be paid before support services can begin.
•	
•	Annual Services Fee – Each year, non-public assistance child support cases (cases that public assistance has never been provided) are charged a non-refundable $25 fee after at least $500 in support payments has been paid to the family. The annual service fee is automatically deducted from support payments made to the custodian, and is collected during each federal fiscal year, from Oct. 1 through Sept. 30.
•	Administrative Offset Fees – Department of Revenue or Internal Revenue Service (IRS) fees may be deducted from the noncustodial parent’s tax refund(s) collected for past due support before being disbursed as a support payment to the custodial parent. The noncustodial parent is credited with the full tax refund(s) amount collected.
•	Legal Fees – Agency attorney services and court fees are paid by the agency, or may be charged to the noncustodial parent as allowed by law. There is no cost to a custodial parent for legal fees when a court action is established by the agency. However, any costs for private legal services obtained by either parent are the parent’s responsibility.

PROGRAM DISTRIBUTION
•	Distribution of Support – Support payments are disbursed in accordance with federal regulations. Support payments are paid toward all the noncustodial parent’s current support obligations first, except for tax refund offsets which are paid toward any state debt owed first. Support payments are deposited to an agency-issued debit card or personal bank account. Support payments exceeding the noncustodial parent’s current support obligations are applied to any past due support.
•	Tax Refund Offset – Support payments received from a joint tax return offset may not be distributed for up to six months. The IRS may adjust a refund amount, which may require the custodial parent to return some or all a support payment received from a tax refund. Tax refund offsets are applied to eligible cases annually.

OTHER PROGRAM POLICIES & INFORMATION
•	Disclosure of SSN – Social Security numbers are obtained and kept on file at the local child support agency to locate and identify individual’s assets for the purposes of establishing, modifying and enforcing child support obligations. Enrolling a child in health care coverage may require the release of the child’s Social Security number and mailing address to the other parent’s employer, or the release of the child’s Social Security number to the other parent.
•	Confidentiality – Child support case records are not public records. The information in your case may be discussed with or given to other state child support services, and/or other public agencies that can legally receive such information and to the other parent or his/her attorney to the extent required by law. If the local child support agency is notified that family/domestic violence is an issue, the local child support agency must take additional steps to further safeguard information.
•	Nondiscrimination – In accordance with the Civil Rights Act of 1964, NCCSS ensures that all individuals are treated equally, and that no person is discriminated against in the selection or eligibility to receive services in any manner prohibited by law.
•	Intergovernmental Cases – Federal law requires every state to enact the Uniform Interstate Family Support Act (UIFSA) 2008 to aid states in working together to establish and enforce child support orders. Every state, and many tribes, foreign countries, territories or tribunals have an agency to enforce child support orders. If parents do not live in the same state, although laws differ, child support agencies work with each other to locate parents and to establish and enforce orders.
•	Case Management Decisions – Local child support agencies determine the appropriate services for child support cases, as well as the way services are delivered by the agency. Reasonable and necessary actions to best serve your case will be considered; however, specific time frames or results cannot be guaranteed.
•	
APPLICANT RIGHTS & RESPONSIBILITIES
All applicants: either parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and judicial officials in a child support case have the following rights and responsibilities:

Rights
•	To make an application for child support services at a local child support agency
•	To be provided information about the status of your child support case
•	To establish an account on the eChild Support website (www.ncchildsupport.com) to access case information
•	To receive notice of all pending court actions and to be provided copies of all court orders from court hearings related to your child support case
•	To request that the support order be reviewed or modified at least every three years
•	To request a review of case management or distribution of funds in your case
•	To hire a private attorney (at your own cost) to represent your interests in the child support case. The child support attorney represents the child support agency, and cannot represent you in child support or other legal matters regarding the child, such as custody and visitation

Responsibilities
•	To provide the child support agency information that may help in the progression of the child support case
•	To attend any appointments and/or hearings for which you have been provided notice that your participation is needed
•	To notify the child support agency of changes in your address and/or employment
•	To notify the child support agency if the child being provided services:
o	Is no longer in your custody
o	Graduates or ceases to attend high school
•	To repay any payments received in error
Additional information about the Child Support program is available at www.ncchildsupport.com
I have read or have had explained to me the above information about the North Carolina Child Support Services program policies, services and my rights and responsibilities. By signing below, I acknowledge that I have received a copy of the above information.

Print Legal Name  	

Signature of Applicant	Date  	

SECTION 1 – APPLICANT/PUBLIC ASSISTANCE RECIPIENT INFORMATION	
I,					 First		Middle		Last
(select the appropriate box, must select one)	
□ DO NOT RECEIVE:
Temporary Assistance for Needy Families (TANF), Work First, Medicaid or Foster Care services from the Department of Social Services for the child(ren) named below. I am applying for services of the child support agency for the benefit of the child(ren) listed below. I understand that this application establishes a contract with North Carolina Child Support Services, and that services will begin once the local child support agency receives the completed application and any
required application fee.	□	AM A RECIPIENT OF: (Select all that apply)
□	Temporary Assistance for Needy Families (TANF)
□	Work First	□ Medicaid	□ Foster Care assistance
for the child(ren) listed below. I understand that eligibility for this assistance may require me to work with the child support agency in pursuing support for the child(ren).
I agree to cooperate fully with these efforts, unless I present good cause and I am granted exemption from this requirement by the Work First, Medicaid, or Foster Care agency.	
Write the full name of each child for whom child support services are being requested:
(If additional space is needed, provide the information on a separate sheet of paper and attach to the application.)	

First	Middle	Last

First	Middle	Last	
Do the child(ren) live with you?
□	Yes - Your role in the support case is the Custodial Parent (CP), if you are or are not the child’s parent
□	No - Your role in the support case is the Noncustodial Parent (NCP)	
Do you currently receive or have you applied for enforcement services from North Carolina, another state, country outside of United States of America (USA) or a private company for support of any of the children included in this application?
□	No
□	Yes – State 	Country  	
□	Name of private company  		
Do you currently employ an attorney or private collection agency for child support?
□	No
□	Yes – Attorney or Agency Name 	Phone No. (	)	—  	
Attorney or Agency Address  		
If you are applying for child support services, may we contact you by email? □ Yes □ No	

Applicant/Public Assistance Recipient Name (Print) 	

Applicant/Public Assistance Recipient Signature 	Date  	

SECTION 2 – CUSTODIAL PARENT/GUARDIAN INFORMATION	
Name								 First		Middle		Last		Suffix (e.g. Jr.)	
Maiden Name: (If applicable)	Alias Name: (If applicable)
 	_	
Gender:
□ Male □ Female	Date of Birth:
 	/ 	/  		Social Security No.:

_	— 	—  		Language Preference: □ English
□ Spanish □ Other  		
Indicate any special assistance that may be needed:
□	Hearing Impaired	□ Visually Impaired
□	Other (Explain)  		Race:
□	Black □ White □ Hispanic □ Asian □ Unknown
□	American Indian Reservation □ Other (Specify)  	
□	American Indian Non-Reservation	
Mailing Address:

Street	City	State	Zip	
Residential Address:

Street	City	State	Zip	
Home Phone No.:
(	)	— 	
Area Code/Number	Cell Phone No.:
(	)	— 	
Area Code/Number	Work Phone No.:
(	)	— 	
Area Code/Number	
Email address: 	_	
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is reason that your information should not be shared with other participants in this case.
□	A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□	I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□	I have no concerns regarding domestic violence now.	
ONLY complete the income section below if the applicant is the child(ren)’s parent. If applicant is NOT a parent, skip this section and go to Section 3.
Is the custodial parent currently employed?
□	Yes - If yes, what is the employer’s name  	
Address				 Phone No. (	)	— 	
□	No - Previous employer 				_		 Date employment ended 	/ 	/ 	Reason 		_	 Usual occupation  							
Income Sources - check all that apply and list the amount(s) below:
□	Military □ Veterans □ Social Security □ Other Retirement □ Unemployment
□	Other Income/Assets not listed above  		
Amount (monthly gross)	Source (list income source)	
$  			
$  			
Total Monthly gross income amount $  		

SECTION 3 – CHILD NO. 1	
Complete Section 3 for EACH child for whom services are requested. If additional space is needed, list the information on a separate sheet of paper and attach to the application.

Name					 First		Middle	Last		Suffix (e.g. Jr.)	
Gender:
□ Male □ Female	Date of Birth:
 	/ 	/  		Social Security No.:
_	— 	—  		Language Preference: □ English
□ Spanish □ Other  		
Indicate any special assistance that may be needed:	Race:
□	Black □ White □ Hispanic □ Asian □ Unknown
□	American Indian Reservation □ Other (Specify)  	
□	American Indian Non-Reservation	
□ Hearing Impaired	□ Visually Impaired		
□ Other (Explain)  			
What is your relationship to this child?	Does the child live with you?		
□ Mother	□	No – If no, with whom does the child live?
 	_
Address				 Phone No. (	)	— 	
□	Yes – If yes,
•	How many nights per year does the child spend in the home?  	
•	How long has the child been in the home? 	Years 	_Months	
□ Father		
□ Alleged Father		
□ Other (Specify relationship)		
Does this child receive: (Select all that apply)
□	TANF/Work First □ Medicaid □ Health Choice □ Foster Care □ Subsidized Child Care
□	Social Security benefits – if yes, □ SSI or □ SSA (disability)
□	Veterans Administrative (VA) Dependent benefits – if yes, veteran’s name  		
List name(s) of parent(s) from whom support is being requested:	List name(s) of parent(s) as shown on child’s birth certificate:	
Parent 1  		Parent 1  		
Parent 2  		Parent 2 	_		
Was the child’s mother married to anyone when the child was conceived or born?
□	No
□	Yes – to whom:  		Was the child born during the marriage of the parents?
□	No - If no, was an Affidavit of Parentage completed?
If yes, in what state?  	
□	Yes - If yes, attach the birth certificate	
City, state, county and country where child was conceived:
City: 	State: 	County:	 Country:  				City, state, county and country of the child’s birth:

City: 	State: 	County:	 Country:  			 	
Has paternity testing been completed for this child and parents?
□ No  □ Yes - Date 	/ 	/ 	
Results  	
(Attach a copy of the results)	Has paternity been established by:
□	Court Order □ Voluntary Acknowledgement □ Other
□	No   □ Yes - Date 	/ 	_ / 	
County	State  	 (Attach copy/other documentation)	

What was the parent’s relationship status at the time of the child’s birth?	
Date	Location (city/county/state)	
□	Married	 	/ 	/  	
□	Separated	 	/ 	/  	
□	Divorced	 	/ 	/  	
□	Never married to each other	

 	

Does this child have health care coverage: (Select all that apply)
□	No
□	Yes - If yes, complete information below (Attach copy of insurance card or other verification of coverage. If additional space is needed, list the information on a separate sheet of paper and attach to the application)
□ Medicaid	□ Health Choice	□ Medical	□ Dental	□ Vision	□ Pharmacy	□ Other Insurance Insurance Provider  						                                                                                                                                                                               Name of Policy Holder  						 Policy Holder Relationship to the Child  						

SECTION 3 – CHILD NO. 2	
Complete Section 3 for EACH child for whom services are requested. If additional space is needed, list the information on a separate sheet of paper and attach to the application.

Name					 First		Middle	Last		Suffix (e.g. Jr.)	
Gender:
□ Male □ Female	Date of Birth:
 	/ 	/  		Social Security No.:
_	— 	—  		Language Preference: □ English
□ Spanish □ Other  		
Indicate any special assistance that may be needed:	Race:
□	Black □ White □ Hispanic □ Asian □ Unknown
□	American Indian Reservation □ Other (Specify)  	
□	American Indian Non-Reservation	
□ Hearing Impaired	□ Visually Impaired		
□ Other (Explain)  			
What is your relationship to this child?	Does the child live with you?		
□ Mother	□	No – If no, with whom does the child live?
 	_
Address				 Phone No. (	)	— 	
□	Yes – If yes,
•	How many nights per year does the child spend in the home?  	
•	How long has the child been in the home? 	Years 	_Months	
□ Father		
□ Alleged Father		
□ Other (Specify relationship)		
Does this child receive: (Select all that apply)
□	TANF/Work First □ Medicaid □ Health Choice □ Foster Care □ Subsidized Child Care
□	Social Security benefits – if yes, □ SSI or □ SSA (disability)
□	Veterans Administrative (VA) Dependent benefits – if yes, veteran’s name  		
List name(s) of parent(s) from whom support is being requested:	List name(s) of parent(s) as shown on child’s birth certificate:	
Parent 1  		Parent 1  		
Parent 2  		Parent 2 	_		
Was the child’s mother married to anyone when the child was conceived or born?
□	No
□	Yes – to whom:  		Was the child born during the marriage of the parents?
□	No - If no, was an Affidavit of Parentage completed?
If yes, in what state?  	
□	Yes - If yes, attach the birth certificate	
City, state, county and country where child was conceived:
City: 	State: 	County:	 Country:  				City, state, county and country of the child’s birth:

City: 	State: 	County:	 Country:  			 	
Has paternity testing been completed for this child and parents?
□ No  □ Yes - Date 	/ 	/ 	
Results  	
(Attach a copy of the results)	Has paternity been established by:
□	Court Order □ Voluntary Acknowledgement □ Other
□	No   □ Yes - Date 	/ 	_ / 	
County	State  	 (Attach copy/other documentation)	

What was the parent’s relationship status at the time of the child’s birth?	
Date	Location (city/county/state)	
□	Married	 	/ 	/  	    	
□	Separated	 	/ 	/  	    	
□	Divorced	 	/ 	/  	    	
□	Never married to each other	
Does this child have health care coverage: (Select all that apply)
□	No
□	Yes - If yes, complete information below (Attach copy of insurance card or other verification of coverage. If additional space is needed, list the information on a separate sheet of paper and attach to the application)
□ Medicaid	□ Health Choice	□ Medical	□ Dental	□ Vision	□ Pharmacy	□ Other Insurance Insurance Provider  						                                                                                                                                                                           Name of Policy Holder  						 Policy Holder Relationship to the Child  						

SECTION 4 – NONCUSTODIAL PARENT INFORMATION NO. 1	

Name						 First		Middle		Last		Suffix (e.g. Jr.)	
Alias Names: (If applicable)	Name(s) of child(ren) for this noncustodial parent:	
Gender:
□ Male □ Female	Date of Birth:
 	/ 	/ 		Social Security No.:

_	— 	— 	_		Language Preference: □ English
□ Spanish □ Other  		
Indicate any special assistance that may be needed:
□	Hearing Impaired	□ Visually Impaired
□	Other (Explain)  		Race:
□	Black □ White □ Hispanic □ Asian □ Unknown
□	American Indian Reservation □ Other (Specify)  	
□	American Indian Non-Reservation	
Birthplace:	Height:  	
Weight:	 Identifying Marks:
 		Hair Color:	Eye Color:	
City	State		□ Bald	□ Blond	□ Black □ Brown	

 		□ Black □ Brown	□ Blue	□ Gray	
County		□ Gray □ Red	□ Green □ Hazel	

Country		□ Unknown	□ Unknown	
Mailing Address:

Street	
 		_		 City	State		Zip	
Residential Address:

Street	
 		_	 City	State Zip	
Home Phone No.:
(	)	—  	
Area Code/Number	Cell Phone No.:
(	)	— 	
Area Code/Number	Work Phone No.:
(	)	— 	
Area Code/Number	
Email address:  		
Does the noncustodial parent have a driver license? □ No □ Yes – Driver License Number  	
State  		
Does the noncustodial parent have a vehicle? □ No □ Yes – Vehicle Make/Model/Year 		
Noncustodial parent’s father name: 	
Noncustodial parent’s mother name:  		

What is the noncustodial parent’s current marital status?
□	Married - Date of marriage 	/ 	/	Name of Spouse  	
□	Separated - Date of separation 	/ 	/	Name of Spouse  	
□	Divorced - Date of divorce	 	/ 	/	Name of Spouse  	                                                                             If multiple marriages/divorces, list dates and name of spouse for each  	 	
Is the noncustodial parent in the military?
□	No
□	Yes – If yes, which branch of the military:
□ Air Force □ Air Force National Guard □ Army □ Army National Guard □ Marine Corps □ Navy
What is his/her current military status: □ Active duty □ Reserve □ Retired □ Separated □ AWOL □Unknown What is his/her last known duty station?   		
Does the noncustodial parent have an arrest record?
□	No
□	Yes – If yes, when was the noncustodial parent arrested? 	                                                                                                       What city and state was the noncustodial parent arrested? 	                                                                                     Is the noncustodial parent currently on parole/probation? □ No □ Yes – If yes, where?

Is the noncustodial parent currently incarcerated? □ No □ Yes – If yes, where?

Is the noncustodial parent currently on work release? □ No □ Yes – If yes, where?	
Is the noncustodial parent currently employed?
□	Yes - If yes, what is the employer’s name  	
Address				 Phone No. (	)	-  	
□	No - Last known employer  					 Date employment ended 	/ 	/ 	Reason		 Usual occupation 				_ 		
Select the noncustodial parent’s income sources - check all that apply and list the amount(s) below:
□	Military	□ Veterans	□ Social Security	□ Other Retirement	□ Unemployment
□	Other Income/Assets not listed above 	__ 		
Amount (monthly gross)	Source (list income source)	
$  			
$  			
$  			
Total Monthly gross income amount $  		

Is there a support order or agreement?
(If additional space is needed, list information on a separate sheet of paper and attach to the application)
□	No	□ Yes - If yes, select the type of support and complete the requested information:
□	Court Order  □ Medical Support   □ Spousal Support   □ Voluntary Agreement (Attach copy of order or agreement) Court docket number 	Order effective date 		County/State	 Amount ordered $ 		per 	Amount past due $ 		 Payor 			Recipient  			
Child(ren) included in order  		
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is reason that your information should not be shared with other participants in this case.
□	A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□	I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□	I have no concerns regarding domestic violence now.	

Below, tell us any additional information about the noncustodial parent.

SECTION 4 – NONCUSTODIAL PARENT INFORMATION NO. 2	
Additional Parent - Complete ONLY if this application for services is for more than one noncustodial parent. If additional space is needed, list information on a separate sheet of paper and attach to the application.

Name						 First		Middle		Last		Suffix (e.g. Jr.)	
Alias Names: (If applicable)	Name(s) of child(ren) for this noncustodial parent:	
Gender:
□ Male □ Female	Date of Birth:
 	/ 	/ 		Social Security No.:

_	— 	—  		Language Preference: □ English
□ Spanish □ Other  		
Indicate any special assistance that may be needed:
□	Hearing Impaired	□ Visually Impaired
□	Other (Explain)  		Race:
□	Black □ White □ Hispanic □ Asian □ Unknown
□	American Indian Reservation □ Other (Specify)  	
□	American Indian Non-Reservation	
Birthplace:	Height:  	
Weight:	 Identifying Marks:
 		Hair Color:	Eye Color:	
City	State		□ Bald	□ Blond	□ Black □ Brown	

 		□ Black □ Brown	□ Blue	□ Gray	
County		□ Gray □ Red	□ Green □ Hazel	

Country		□ Unknown	□ Unknown	
Mailing Address:

Street	
 		_		 City	State		Zip	
Residential Address:

Street	
 		_	 City	State Zip	
Home Phone No.:
(	)	—  	
Area Code/Number	Cell Phone No.:
(	)	— 	
Area Code/Number	Work Phone No.:
(	)	— 	
Area Code/Number	
Email address:  		
Does the noncustodial parent have a driver license? □ No □ Yes – Driver License Number  	
State  		
Does the noncustodial parent have a vehicle? □ No □ Yes – Vehicle Make/Model/Year 		
Noncustodial parent’s father name: 	
Noncustodial parent’s mother name:  		

What is the noncustodial parent’s current marital status?
□	Married - Date of marriage 	/ 	/	Name of Spouse  	
□	Separated - Date of separation 	/ 	/	Name of Spouse  	
□	Divorced - Date of divorce	 	/ 	/	Name of Spouse  	                                                                             If multiple marriages/divorces, list dates and name of spouse for each  	 	
Is the noncustodial parent in the military?
□	No
□	Yes – If yes, which branch of the military:
□ Air Force □ Air Force National Guard □ Army □ Army National Guard □ Marine Corps □ Navy
What is his/her current military status: □ Active duty □ Reserve □ Retired □ Separated □ AWOL □Unknown What is his/her last known duty station? 	_	
Does the noncustodial parent have an arrest record?
□	No
□	Yes – If yes, when was the noncustodial parent arrested? 	                                                                                                       What city and state was the noncustodial parent arrested? 	                                                                                     Is the noncustodial parent currently on parole/probation? □ No □ Yes – If yes, where?

Is the noncustodial parent currently incarcerated? □ No □ Yes – If yes, where?

Is the noncustodial parent currently on work release? □ No □ Yes – If yes, where?	
Is the noncustodial parent currently employed?
□	Yes - If yes, what is the employer’s name  	
Address				 Phone No. (	)	-  	
□	No - Last known employer  					 Date employment ended 	/ 	/ 	Reason		 Usual occupation 				_ 		
Select the noncustodial parent’s income sources - check all that apply and list the amount(s) below:
□	Military	□ Veterans	□ Social Security	□ Other Retirement	□ Unemployment
□	Other Income/Assets not listed above 	__ 		
Amount (monthly gross)	Source (list income source)	
$  			
$  			
$  			
Total Monthly gross income amount $  		

Is there a support order or agreement?
(If additional space is needed, list information on a separate sheet of paper and attach to the application)
□	No	□ Yes - If yes, select the type of support and complete the requested information:
□	Court Order  □ Medical Support   □ Spousal Support   □ Voluntary Agreement (Attach copy of order or agreement) Court docket number 	Order effective date 		County/State	 Amount ordered $ 		per 	Amount past due $ 		 Payor 			Recipient  			
Child(ren) included in order  		
Confidentiality of Personal Information
NCCSS uses personal information only as allowed by law for seeking child support. Indicate below whether there is reason that your information should not be shared with other participants in this case.
□	A protective order has been entered due to domestic violence concerns. (Attach a copy of the order)
□	I have concerns about my or the child’s safety due to circumstances involving domestic violence.
□	I have no concerns regarding domestic violence now.	

Below, tell us any additional information about the noncustodial parent.

 

SECTION 5 – ATTACHMENTS

Check all items that are attached to this application. If an item is not listed, check “Other” and list the item(s) attached
(including any documents, orders, photos, statements, etc.)
•	Copy of the birth certificate and Social Security card for each child included in this application
•	Copy of your Photo ID (e.g. driver’s license)
•	Photo of the child’s other parent(s)
•	Verification of your income, not required if you are not the child’s parent (e.g. pay stubs, tax returns)
•	Copy of the marriage certificate of the child’s parents (if not available, provide dates of marriage and/or other verification of marital status of the children’s parents)
•	Copies of any legal documents related to the child(ren) included in this application (if not available, list the date, county, state of filing and court case number for the documents):
•	Affidavit of Parentage
•	Paternity order
•	Child support and/or spousal support Order (initial and all modification orders)
•	Voluntary agreement for child support
•	Divorce decree and/or separation agreement
•	Order terminating parental rights
•	Domestic violence protective order
•	Other   	

SECTION 6 – OTHER INFORMATION

Provide additional information that may assist Child Support Services in processing your application.

SECTION 7 – CERTIFICATION STATEMENT

I hereby certify that I have provided all requested information that is available to me and that it is true and correct to the best of my knowledge. I agree to meet all obligations and duties assigned to me.

Print Legal Name  	

Signature of Applicant 	Date  	

(APPLICANT COPY)
North Carolina Child Support Services (NCCSS) administers the North Carolina child support program under Title IV-D of the Social Security Act. Services are available to a parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and judicial officials. The child support program’s goal is to provide the best possible services to families for children. Whether you are making an application for child support services as a recipient of assistance from other social services programs (Temporary Assistance to Needy Families [TANF], Foster Care and/or Medicaid) or requesting child support services as a non-public assistance applicant, your involvement, information, and contributions are important and required.
NORTH CAROLINA CHILD SUPPORT SERVICES INFORMATION PROGRAM SERVICES
NCCSS provide child support services to assist families in meeting their financial obligations for children. There is no residency or
citizenship eligibility requirement for services. Depending on the circumstances of each family, one or more of the following services may be appropriate:
•	Location of noncustodial parent – State, federal, local and national resources are used to assist in collecting information about a parent, such as their residence, employment and/or financial assets.
•	Paternity establishment – A determination of parental legal responsibility for the child(ren) is necessary before a parent can be required to pay support. If a child’s parents were not married to each other at the time of the child’s birth, arrangement of paternity testing may be offered to the parties, if appropriate.
•	Support establishment – In North Carolina, support is determined using the guidelines established in State law. N.C. Child Support Guidelines consider both parent’s monthly gross incomes, the amount of time the child spends with each parent and various expenses. NCCSS seeks to establish a court order requiring a parent to provide child and/or medical support for child(ren) based on the N.C. Child Support Guidelines.
•	Collection of support – Child support payments through bank draft, money order or check are sent to N.C. Child Support Centralized Collection (NCCSCC). A large amount of child support payments is deducted from a parent’s wages and sent to NCCSCC by an employer. North Carolina Child Support Services records and disburses all collected child support payments to families by personal direct deposit into a bank account or debit card.
•	Enforcement of support – Enforcement of an established or existing child support, spousal support, and/or medical support court order is met by wage withholding, tax refund offset, liens, professional license/passport revocation, credit reporting, court action, or other collection remedies. Support orders may be reviewed for modification (increase/decrease) every three years or more often, if warranted.
NCCSS does not provide the following services: custody, visitation, or the establishment of spousal support obligations.
PROGRAM FEES
•	Application Fee – Families receiving public assistance (TANF, Medicaid and/or Foster Care) are not charged an application fee for support services. Families that are not receiving public assistance are charged a non-refundable application fee of up to $25. If the applicant’s income is below 100% of the Federal Poverty Guidelines, a reduced application fee of $10 is available. Contact your local child support agency for additional information about qualifying for the reduced application fee. The application fee must be paid before support services can begin.
•	Annual Services Fee – Each year, non-public assistance child support cases (cases that public assistance has never been provided) are charged a non-refundable $25 fee after at least $500 in support payments has been paid to the family. The annual service fee is automatically deducted from support payments made to the custodian, and is collected during each federal fiscal year, from Oct. 1 through Sept. 30.
•	Administrative Offset Fees – Department of Revenue or Internal Revenue Service (IRS) fees may be deducted from the noncustodial parent’s tax refund(s) collected for past due support before being disbursed as a support payment to the custodial parent. The noncustodial parent is credited with the full tax refund(s) amount collected.
•	Legal Fees – Agency attorney services and court fees are paid by the agency, or may be charged to the noncustodial parent as allowed by law. There is no cost to a custodial parent for legal fees when a court action is established by the agency. However, any costs for private legal services obtained by either parent are the parent’s responsibility.
PROGRAM DISTRIBUTION
•	Distribution of Support – Support payments are disbursed in accordance with federal regulations. Support payments are paid toward all the noncustodial parent’s current support obligations first, except for tax refund offsets which are paid toward any state debt owed first. Support payments are deposited to an agency-issued debit card or personal bank account. Support payments exceeding the noncustodial parent’s current support obligations are applied to any past due support.
•	Tax Refund Offset – Support payments received from a joint tax return offset may not be distributed for up to six months. The IRS may adjust a refund amount, which may require the custodial parent to return some or all a support payment received from a tax refund. Tax refund offsets are applied to eligible cases annually.
•	
OTHER PROGRAM POLICIES & INFORMATION
•	Disclosure of SSN – Social Security numbers are obtained and kept on file at the local child support agency to locate and
identify individual’s assets for the purposes of establishing, modifying and enforcing child support obligations. Enrolling a child in health care coverage may require the release of the child’s Social Security number and mailing address to the other parent’s employer, or the release of the child’s Social Security number to the other parent.
•	Confidentiality – Child support case records are not public records. The information in your case may be discussed with or given to other state child support services and or other public agencies that can legally receive such information and to the other parent or his/her attorney to the extent required by law. If the local child support agency is notified that family/domestic violence is an issue, the local child support agency must take additional steps to further safeguard information.
•	Nondiscrimination – In accordance with the Civil Rights Act of 1964, NCCSS ensures that all individuals are treated equally, and that no person is discriminated against in the selection or eligibility to receive services in any manner prohibited by law.
•	Intergovernmental Cases – Federal law requires every state to enact the Uniform Interstate Family Support Act (UIFSA) 2008 to aid states in working together to establish and enforce child support orders. Every state and many tribes, foreign countries, territories or tribunals have an agency to enforce child support orders. If parents do not live in the same state, although laws differ, child support agencies work with each other to locate parents and to establish and enforce orders.
•	Case Management Decisions – Local child support agencies determine the appropriate services for child support cases, as well as the way services are delivered by the agency. Reasonable and necessary actions to best serve your case will be considered; however, specific time frames or results cannot be guaranteed.
APPLICANT RIGHTS & RESPONSIBILITIES
All applicants: either parent, alleged fathers, non-parent caretakers, minor children, social services agencies, and judicial officials in a child support case have the following rights and responsibilities:
Rights
•	To make an application for child support services at a local child support agency
•	To be provided information about the status of your child support case
•	To establish an account on the eChild Support website (www.ncchildsupport.com) to access case information
•	To receive notice of all pending court actions, and to be provided copies of all court orders from court hearings related to your child support case
•	To request that the support order be reviewed or modified at least every three years
•	To request a review of case management or distribution of funds in your case
•	To hire a private attorney (at your own cost) to represent your interests in the child support case. The child support attorney represents the child support agency and cannot represent you in child support or other legal matters regarding the child, such as custody and visitation
Responsibilities
•	To provide the child support agency information that may help in the progression of the child support case
•	To attend any appointments and/or hearings for which you have been provided notice that your participation is needed
•	To notify the child support agency of changes in your address and/or employment
•	To notify the child support agency if the child being provided services:
o	Is no longer in your custody
o	Graduates or ceases to attend high school
•	To repay any payments received in error
Additional information about the Child Support program is available at www.ncchildsupport.com