OFFICE OF THE APPLICATION FOR CHILD SUPPORT ENFORCEMENT SERVICES PROSECUTING You have asked that the Johnson County Child Support Division enforce your case. ATTORNEY Please note that we only enforce Johnson County Child Support Orders. If your child support order is in another county, you may initially apply for child support services in Johnson County, but our office will forward your application to the county of your order for enforcement. If you receive TANF or Medicaid in another county, the county in which you receive TANF or Medicaid will be responsible for establishing paternity and/or your child support order. Please provide all of the required documentation on the following checklist: 1. ______ A completed “Application for Title IV-D Child Support Services” BRADLEY D. COOPER (attached). Johnson County Prosecuting Attorney 2. ______ A signed “Child Support Enforcement Services Waiver” (attached). 1 Caisson Drive, Ste. A Franklin, Indiana 46131 3. ______ A signed “Termination of Child Support Services Notice” (attached). Tel: 317-346-4584 Fax: 317-736-5709 4. ______ A completed “Affidavit of Direct Payments Received” (attached). Lori M. Lampert 5. ______ A completed “Pro Se Appearance” Form (attached). Supervising Deputy Child Support Division 6. ______ One (1) copy of your driver’s license or picture I.D. card for identification Lisa Lancaster purposes. Child Support Coordinator 7. ______ One (1) copy of the Paternity Affidavit signed by the father, if it is applicable to your case. (This document can be obtained at the Health Department in Maryjo Lykins the county of the child’s birth. NOTE: a Paternity Affidavit is not a Birth Investigator Certificate). 8. ______ Three (3) certified copies of your Divorce Decree or Child Support Order. Child Support (Certified copy means the Clerk of the Court has placed a seal on the document Enforcement Agents: stating that it is an accurate copy and has not been tampered with. Use the “Request Cindy Myers for Certified Child Support Documentation” form provided in your application Felony packet to obtain these certified copies free of charge). Heather Woodlee 9. ______ Three (3) certified copies of any changes in the court order for current child Payor A-Col support and the most recent court order showing an established arrearage amount. Linda Bowers 10. ______ One (1) certified copy of all child support payments made on your case (this Payor Com-E document can be obtained at the County Clerk of the Court). Marcy Klem 11. ______ If you DO NOT currently receive TANF or Medicaid, a one-time Payor F-J application fee of twenty-five dollars ($25.00) must be included with your Christina Graham application. The fee must be made by money order or cashier’s check made payable Payor K-Pq to the Indiana Department of Child Services. We cannot accept cash or personal checks. Larra Young Payor Pr-Spq 12. ______ If you DO currently receive TANF or Medicaid, the application fee will be waived if you provide proof of assistance received (For example: one copy of your Hannah Griffin Medicaid cards). Payor Spr-Z After you have obtained all of the required documentation listed above, please contact the Johnson County Child Support Division at (317)346-4584 on Tuesday or Thursday to schedule an appointment with an enforcement agent to initiate the child support enforcement process. We look forward to hearing from you. APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 1) State Form 34882 (R6/12-92) DFC Form 425A Complete one application for each absent parent for whom application is made. PRIVACY STATEMENT Indiana Department of Child Services The records in this series are confidential according to 45 CFR 303.21. CHILD SUPPORT BUREAU This agency is requesting disclosure of personal information that is 402 W. Washington St. Rm. W360 necessary to accomplish the statutory purpose of the agency according to 45 CFR 303.70. Disclosure of this information is mandatory. Failure to Indianapolis, IN 46204 provide any information may prevent this form from being processed. INSTRUCTIONS (please read) The Indiana Child Support Bureau offers child support services to persons desiring to obtain child support from a responsible parent outside the home. These services are: Complete Service or Parent Locator Only Service. ALL FEES FOR SERVICES ARE NONREFUNDABLE. COMPLETE SERVICE: The applicant will be entitled to all services offered by the IV-D program as long as the case remains active. This service shall include the Parent Locator Service and the legal services of the local IV-D agency. These services include Establishing Paternity,/Establishing and/or Enforcing a support obligation (including health insurance coverage). The complete service does NOT include handling a divorce case, enforcement of custody or visitation provisions, nor matters other than those associated with the support of dependent children. All support payments may be directed to the State for monitoring and disbursement. ANY COSTS INCURRED IN EXCESS OF THE APPLICATION FEE, SUCH AS COURT COSTS, WITNESS FEES, BLOOD TEST COSTS, IRS INTERCEPT FEES AND ADMINISTRATIVE COSTS ASSOCIATED WITH THIS CASE MAY BE CHARGED AGAINST THE APPLICANT. In addition the Tax Refund Intercept Project may be used to collect child support arrearages. Application for complete service does not guarantee, however, that your case will be submitted for tax refund intercept nor that tax refund monies will be collected. In order to certify a case for intercept, there must be a valid child support order, the absent parent must be at least $500 in arrears, and the applicant must have the absent parent's Social Security number. If any children of the absent parent have received TANF/AFDC in the past, any collection made from an intercept will first be applied by the State to any unreimbursed public assistance on any former TANF/AFDC case. If the IRS, for any reason, reclaims all or any portion of an intercepted refund that has already been paid to you, you are obligated to repay the State of Indiana the amount reclaimed by the IRS. You authorize that any such repayment may be deducted from support collected on your behalf if other arrangements have not been made and fulfilled. PARENT LOCATOR SERVICE: The applicant will be entitled to all resources offered by the State and Federal Parent Locator Service until a verified address is provided or all sources for location are exhausted. The payment of the application fee does not guarantee a successful location. The success will greatly depend on the applicant's own knowledge about the absent parent. If all sources of information are exhausted without a successful location, the applicant will be notified. Upon notification,the applicant will have six months to provide additional information. If no additional information is provided within the six month period, the case will be closed and the applicant notified. TERMINATION OF SERVICES: The applicant may terminate services only if any charges due or overpayments owing are paid, by notifying the Child Support Bureau in writing that services are no longer desired. The State may terminate services only in accordance with 45 C.F.R. 303.11. Services in respect to this application will also terminate if the applicant receives TANF/AFDC. APPLICANT'S OBLIGATIONS: The applicant is expected to fully cooperate with the local IV-D agency in the legal and non-legal preparation of the case, including, but not limited to notifying the local IV-D agency of change of address, supplemental information regarding the absent parent, reuniting with the absent parent, and other information pertinent to the case. THE APPLICANT MUST ALSO NOTIFY THE CHILD SUPPORT BUREAU AT THE ABOVE ADDRESS OF ANY CHANGE OF ADDRESS. APPLICANT'S STATEMENT I affirm that the information in this application is true and correct and that false information could result in perjury charges against me. I understand that I am to cooperate with the local IV-D agency in order for my case to be processed, and non-cooperation can result in termination of my case. I further understand that payment of the application fee does not guarantee successful action on the case but rather all reasonable attempts, will be made in my behalf to obtain successful results for the service requested. I have read and understand the above NOTICE. I hereby request the following service under the terms outlined above. __Complete Service __Parent Locator Service Only Signature of applicant Date signed (mo., day, yr.) ____________________________________ _______________ Application taken by Case Number Fee Paid ____________________________________ ________________ $_________________ APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 2) State Form 34882 (R6/12-92) DFC Form 425A PART II: APPLICANT DATA 1. Full name of applicant (last, first and middle initial) ________________________________________________________ Maiden Name (if applicable) __________________ 2. Date of birth (mo., day, yr.) ___________________ Sex _____ Race _____ Social Security number ___________________ 3. Address of applicant (street and number or rural route number) ____________________________________________________ Apt. or room number ___________ City _______________State _______ ZIP code _______________ 4. My mailing address is: ______ Same as above Different (if different, print below) 5. Contact Information: Telephone number (home) ( ) ____________ Telephone number (work) ( ) ______________ Cell Phone ( ) ______________ Email address: ____________________________________________ 6. Name and address of other person who will always know my whereabouts: Name Telephone number ( ) Address (street, city, state, ZIP code) Relationship to me 7. Have you ever received an AFDC/Welfare check in Indiana? Yes: _____________ No: ______________ If "Yes" give the month and year of last check. _________________________________________________ PART III: DEPENDENT DATA/CHILD DATA I wish to secure support payments on behalf of the following children. CHILD'S FULL NAME SEX BIRTHDATE PLACE OF BIRTH SOCIAL SECURITY # RELATIONSHIP TO ME (Last, first, M.I.) (mo., day, yr.) 1. 2. 3. 4. 5. 6. APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 3-a) State Form 34882 (R6/12-92) DFC Form 425A _______________________________________________________________________________________________________________ PART IV: ABSENT PARENT DATA Applicant (Custodial Parent Name) A. Full name of absent parent (last, first and middle) Alias or maiden name (last, first, middle) Social Security number Date of birth Age Place of birth (city and state) Race Height Weight Hair Eyes B. Absent parent's address Street name and number or rural route number Apt. or room number Current Last known (years) City State ZIP code Additional Contact Information: Home Phone Number: ____________________ Work Phone Number: _________________________ Cell Phone Number: ___________________ Email address: ________________________________ C. Name of employer: ________________________________________ Current _____ Last known ________ (years) Street name and number or rural route number ________________________________________________ City ________________________ State ________ Zip Code __________ Usual type of work _________________________ D. Marital status of children's parents Date married ________________ Location married ______________________ Married Deserted Divorced Never married Date separated or divorced ___________ Location separated or divorced _________________ Separated Unknown E. Complete if parent: Is currently Or has been in the military service F. Names of the absent parent's Branch of service Army Navy Marines Air Force Coast Guard children. (check blank in front of Rank Officer Enlisted Service number name if there is "No" support order for this child.) G. Prior arrest record Yes No Date: ____________ Location:______________ The absent parent is currently as been in the past in a jail, prison or institution Name of institution 1. Date sentenced Address (city, state or county) Date released 2. H. Absent parent's father's name 3. Address (city, state or county) 4. H. Absent parent's mother's maiden name 5. Address (city, state or county) 6. I. Other contact person for absent parent Verification and comments Address (city, state or county) APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 3-b) State Form 34882 (R6/12-92) DFC Form 425A PART IV: (continued) COURT ORDER INFORMATION: J. COMPLETE THIS SECTION IF CHILD IS BORN OUT OF WEDLOCK (Place all other paternity information in comment section) Has paternity suit been filed? Yes No Date filed:_______________ Location filed:_________________________ Has paternity been established by court order? _____ Yes ____ No Has parent ever paid support or medical or bought things for the children? Yes ____ No Amount $________ Frequency _______________ K. COURT DATA (all applicants must complete this section) Has parent ever been ordered by a court to pay support for these children? _____ Yes _____No Name of court_______________________________________ If No, has a petition been filed and a hearing pending? _____ Yes ______ No Address of court Cause number of court order ______________________________ Amount $__________ Frequency _________________ Absent parent paying support Yes No To whom does parent pay support? ________________________________ Date last paid _______________ Is parent paying military allotment? Yes No Amount $ ______________ APPLICATION FOR TITLE IV-D CHILD SUPPORT SERVICES (page 4) ASSIGNMENT FOR COLLECTION FOR PERSONS NOT RECEIVING PUBLIC ASSISTANCE Name of absent parent CHILDREN'S NAMES 1. 5. 2. 6. 3. 7. 4. 8. AGREEMENT I understand and agree that support payments collected hereafter from the absent parent names above on behalf of myself and/or the above named children will be paid to the Division of Family and Children, Family and Social Services Administration, and that said support payments will be paid to me by the agency after deduction of any charges due and owing to that agency. Such charges are explained in page one of the "Application for Title IV-D Child Support Services" executed by the applicant. This authorization shall continue in effect until terminated in the manner set forth on page one of the "Application for Child Support Services". Printed name of applicant Signature of applicant Date signed (mo., day, yr.) Cause number or support order Court name OFFICE OF THE TITLE IV-D CHILD SUPPORT ENFORCEMENT SERVICES WAIVER PROSECUTING ATTORNEY The undersigned custodial parent acknowledges that the Johnson County Prosecutor’s Office is an agent of the State of Indiana and the Department of Child Services and cannot serve as a private attorney to custodial parents. The function of the Prosecuting Attorney’s Office is to protect and promote the interests of the State of Indiana and the best interests of the children, and these interests may conflict at times with the interests of the custodial parent. Pursuant to Title IV-D of the Social Security Act, the Child Support Office of the Johnson County Prosecuting Attorney provides four (4) basic services: BRADLEY D. COOPER 1. The location of obligated parents. Johnson County 2. The establishment of paternity and child support orders Prosecuting Attorney 3. The enforcement of child support orders. 1 Caisson Drive, Ste. A 4. The modification of child support orders. Franklin, Indiana 46131 Tel: 317-346-4584 Pursuant to the mandate of Title IV-D, the Prosecutor’s Office is not allowed to provide Fax: 317-736-5709 representation, or be involved in, matters that deal with visitation, custody and property settlement. You should consult with a private attorney, legal aid or access Lori M. Lampert Supervising Deputy http://www.in.gov/judiciary/selfservice/ concerning those issues. Child Support Division The undersigned acknowledges that they are not entering into an attorney-client Lisa Lancaster relationship with any attorney in the Johnson County Prosecutor’s Office. Accordingly, Child Support any confidential information provided to this office is not information protected by an Coordinator attorney-client relationship. Therefore, information provided to the Office of the Prosecuting Attorney may be used by the Office in the prosecution of criminal offenses Maryjo Lykins or civil violations without regard to the source of the information. The undersigned Investigator acknowledges that his/her involvement in the Title IV-D Child Support Enforcement Service does not protect him/her from prosecution for any criminal offense or civil Child Support infraction. Enforcement Agents: Cindy Myers Felony NOTE: THIS FORM IS A WAIVER OF LEGAL RIGHTS AND SHOULD BE Heather Woodlee SIGNED ONLY AFTER BEING READ CAREFULLY YOUR SIGNATURE Payor A-Cla VERIFIES THAT YOU HAVE READ AND UNDERSTOOD THE CONTENTS OF THIS FORM. Linda Bowers Payor Clb-Ge Marcy Klem Payor Gf-La I have read the above information in full and understand the contents of this waiver and consent to its terms. Christina Graham Payor Lb-Ra Larra Young Payor Rb-Sta ________________________________ ________________________ Hannah Griffin Payor Stb-Z Custodial Parent Signature Date OFFICE OF THE TERMINATION OF CHILD SUPPORT SERVICES NOTICE PROSECUTING This is to notify you, as a person who is utilizing government services, that the ATTORNEY Johnson County Prosecutor’s Office will terminate IV-D Child Support Enforcement Services1 on your case(s) for any of the following reasons: 1. Hiring private counsel regarding child support; 2. Filing motions with the court on your own behalf regarding child support; 3. Providing false information to any member of the Johnson County BRADLEY D. COOPER Johnson County Prosecutor’s office, including but not limited to, an enforcement agent, Prosecuting Attorney the deputy prosecutor or the child support intake line; 1 Caisson Drive, Ste. A Franklin, Indiana 46131 4. Providing false information to any member of the Johnson County Tel: 317-346-4584 Court System, including but not limited to, a Judge, bailiff, Fax: 317-736-5709 receptionist or hearing facilitator; Lori M. Lampert 5. Failure to keep the Johnson County Prosecutor’s Office or court Supervising Deputy notified of your current telephone number and address; Child Support Division Lisa Lancaster 6. Failure to appear for appointments or required court hearings; Child Support Coordinator 7. Failure to discuss private agreements impacting child support in advance with a Johnson County Prosecutor’s Office child support Maryjo Lykins enforcement agent, including but not limited to custody changes, Investigator agreed entries, modifications, etc.; 8. Failure to provide documents necessary to litigate your case, including Child Support but not limited to, court orders, agreed entries and paternity affidavits; Enforcement Agents: 9. Continued acceptance of direct child support payments in violation of Cindy Myers the Johnson County Prosecutor’s Office policy; Felony Heather Woodlee 10. A demand or request that the Johnson County Prosecutor's Office act Payor A-Cla unethically, illegally or outside the bounds of the law after having been informed of the illegality or infeasibility of demand or request; Linda Bowers Payor Clb-Ge 11. Signing on with any other child support collection agency, including but not limited to, www.supportkids.com; Marcy Klem Payor Gf-La 12. Objecting to incarceration of the non-custodial parent in reference to Christina Graham civil or criminal child support hearings; Payor Lb-Ra 13. Contacting the non-custodial parent’s place of employment regarding Larra Young any issues related to child support; Payor Rb-Sta Hannah Griffin Payor Stb-Z 1 Termination of a child support case includes termination of the following services: enforcement of a child support order, establishment of a child support order, parent locator services, paternity establishment, income withholding orders and tax refund offsets. If a party using our services is a TANF and/or Medicaid recipient, those benefits may also be sanctioned as a result. OFFICE OF THE PROSECUTING ATTORNEY TERMINATION OF CHILD SUPPORT SERVICES NOTICE (cont.) 14. Failure to provide documentation to the Johnson County Prosecutor’s Office Child Support Division regarding Social Security Benefits that the minor child is receiving as a derivative of the non-custodial parent’s Social Security Disability. BRADLEY D. COOPER 15. Any instance of abusive, condescending, demeaning, obscene or vulgar language in Johnson County the Johnson County Prosecutor’s Office, in the courtroom or court lobby, via Prosecuting Attorney telephone or email to any member of the Johnson County Prosecutor’s staff by the 1 Caisson Drive, Ste. A custodial parent or any third party acting on behalf of the custodial parent; Franklin, Indiana 46131 Tel: 317-346-4584 16. Any instance of rude, disruptive, abusive or disorderly conduct in the Johnson Fax: 317-736-5709 County Prosecutor’s Office, in the courtroom or court lobby, via telephone or email to any member of the Johnson County Prosecutor’s staff including, but not limited to, shouting at staff, interrupting staff, or hanging up the telephone during a call, by Lori M. Lampert the custodial parent or any third party acting on behalf of the custodial parent; Supervising Deputy Child Support Division 17. Threats made to Johnson County Prosecutor’s Office staff by the custodial parent or any third party acting on the behalf of the custodial parent; Lisa Lancaster Child Support 18. A criminal act committed against any member of Johnson County Prosecutor’s Coordinator Office staff by the custodial parent or any third party acting on the behalf of the custodial parent; Maryjo Lykins Investigator I hereby acknowledge that I have received and read the above referenced Termination of Services. I further acknowledge that my signature on said Child Support document shall serve as my request for immediate termination of all IV-D Child Enforcement Agents: Support Enforcement Services for non-cooperation, including being sanctioned Cindy Myers from any TANF and/or Medicaid Benefits that I receive if the offense is subject to Felony being sanctioned, with no further action or notification necessary. Heather Woodlee Payor A-Cla ______________________________ ________________________ Linda Bowers Custodial Parent Signature Date Payor Clb-Ge Marcy Klem Payor Gf-La Christina Graham Payor Lb-Ra Larra Young Payor Rb-Sta Hannah Griffin Payor Stb-Z STATE OF INDIANA ) IN THE JOHNSON CIRCUIT COURT )SS: JUVENILE & FAMILY DIVISION COUNTY OF JOHNSON ) CAUSE NO. ________________________________ _______________________ ) Petitioner, ) ) vs. ) ) _______________________ ) Respondent. ) AFFIDAVIT OF DIRECT PAYMENTS Comes now the Affiant, _____________________________________________, and states as follows: 1. The Respondent has paid to me a total of $ ___________________ in direct payments, from the date of _______________________ to _______________________. 2. I will not accept any further direct payments of child support from the Respondent from this point forward or I will be terminated from the Johnson County Title IV-D Child Support Enforcement Program without further notice. 3. I understand that the State of Indiana will request an arrearage determination hearing from the court to present evidence on the amount of direct payments that will be deducted from the Respondent’s child support arrearage owed to me. 4. I hereby AFFIRM under the penalties for perjury that the foregoing representations are true. FURTHER AFFIANT SAITH NOT. _________________________________ _________________________________ Signature Printed Name Subscribed and sworn to before me, a Notary Public, in and for the said County and State, on __________ day of ____________________, ___________. ____________________ ____________________________________ COMMISSON EXPIRES NOTARY PUBLIC STATE OF INDIANA ) IN THE JOHNSON CIRCUIT COURT )SS: JUVENILE & FAMILY DIVISION COUNTY OF JOHNSON ) CAUSE NO. ________________________________ _______________________ ) Petitioner, ) ) vs. ) ) _______________________ ) Respondent. ) NOTICE OF PRO SE APPEARANCE I am the _____ Petitioner _____ Respondent in this matter. I enter my pro se appearance; I will represent myself. Unless I, or an attorney, notify the Court otherwise, no attorney will represent me in this matter. In representing myself, I understand that it is my responsibility to: Notify the Court, in writing, of any changes in my address, employment or telephone numbers; Always include my cause number, name, address and telephone number on all correspondence I file with the Court; and Send copies of all papers I file with the Court to the other party involved in this matter. All Court papers may be mailed to me by First Class Mail at the address listed below. Service Address: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ________________________________ ____________________________________ Date Signature of Party Appearing ____________________________________ Printed Name of Party Appearing Distribution: Johnson County Prosecutor’s Office Petitioner/Respondent OFFICE OF THE PROSECUTING ATTORNEY CLERK OF THE COURT: RE: ___________________________________________________ Cause Number: __________________________________________ BRADLEY D. COOPER Johnson County Prosecuting Attorney 1 Caisson Drive, Ste. A Franklin, Indiana 46131 REQUEST FOR CERTIFIED CHILD SUPPORT DOCUMENTATION Tel: 317-346-4584 Please provide The Johnson County Child Support Division with three (3) certified Fax: 317-736-5709 copies of the following information: Lori M. Lampert 1. Divorce Decree and/or Paternity Order; Supervising Deputy Child Support Division 2. Certified payment history of all payments made, including all Pre- ISETS payments; and Lisa Lancaster Child Support Coordinator 3. Any modification Order that would affect the calculation of the child Maryjo Lykins support Order for the above referenced individuals. Investigator Child Support Enforcement Agents: The person wishing to collect child support has been authorized to pick up these Cindy Myers copies for the Johnson County Child Support Division and should not be charged Felony any fee for certification and copies of the documents. Heather Woodlee Payor A-Cla Linda Bowers Payor Clb-Ge Deputy Prosecuting Attorney Marcy Klem Johnson County Child Support Enforcement Payor Gf-La Christina Graham Payor Lb-Ra Larra Young Payor Rb-Sta Hannah Griffin Payor Stb-Z ATTENTION: You must give the clerk and/or the court staff sufficient notice to obtain these copies.
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