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

   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.

To top