For official use only: (Quick reference) Control #: _2012-_________________ CID #: _________________________ CSEO: _________________________ Child Support “Buy to Fly” Passport Denial Amnesty Program APPLICATION FORM Applicant Full Name: _________________________________________ Date: ________________________ Social Security No.: _________-_______-___________ Date of Birth: ___________/_______/___________ Child Support Case No.: _________________ CS Enforcement Officer: ______________________________ Contact Info: Cell: ___________________ Home: ____________________ Other: ____________________ Email address: ____________________________________________ Fax no.: ________________________ Are you employed? _____Yes _____No If so, where are you employed? ______________________________ Mailing Address: __________________________________________________________________________ Physical Address: __________________________________________________________________________ Support Amount Owed (if known or estimate): $__________________ Reason why passport is needed: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ For AG’s Office Use Only Received by: _________________________________________ Date Received: ______________________ Print Name & Initial For review by: ________________________________________ Deadline for approval: _____/____/_______ Applicant: Eligible for Program Not eligible for Program Case Notes: Child Support “Buy to Fly” Passport Denial Amnesty Program GUIDELINES/CRITERIA Completed form must be received by our office no later than 5:00 PM on Friday, August 31, 2012. Must submit two copies of the application. One will be stamped received for your copy. Once submitted process time is approximately 2 weeks from receipt of application. Applying for the program does NOT guarantee an applicant may be eligible for the “Buy to Fly” Program. Upon determination, payment must be made for program arrangements to be effective. Payment terms are as follows: $1,000 OR 10% of the arrears balance, whichever amount is greater. If arrears balance is less than $1,000, balance must be paid in full. If balance remains, there must be a promissory agreement put into effect. Once the agreement is broken the program arrangement terms become void and Passport Denial Program terms go back into effect. If you have any questions or for further information please contact Marissa Crisostomo at 475-3360 ext. 1020. *Subject to change.
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