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Get MS MDHS-CSE-675 2018-2023

First Middle Maiden Last CHILD REN INFORMATION ON THIS CASE ONLY 1ST Child s Name Cit Educ City State of Birth SSN Relationship to CP DOB Sex State of Conception Eth 2nd Child s Name 4th Child s Name Do the children have health insurance coverage CUSTODIAL PARENT CP INFORMATION Are you the legal/biological parent Yes No If no complete other biological parent information below. MISSISSIPPI MDHS-CSE-675 Revised 09-01-14 County Use Only Case ID CP Name Full Services 25 Parent Locate Only/No Charge Date Requested Date Mailed/Given Date Received MDHS-CSE-614 Attached Yes No Mississippi Department of Human Services Division of Field Operations Application for Child Support Services I am applying for support services on behalf of the following child ren. No action will be taken until the application fee is paid There may be additional fees necessary such as court costs filing fees service of process fees DFO does not guarantee that efforts on my behalf will be successful If I do not cooperate with DFO my case may be closed after advance notice and the child care provider notified if applicable I understand the criminal penalties for making false statements and false swearing and do hereby attest to the truthfulness of the information provided. False swearing is punishable by a fine of not more than 1 000 or by imprisonment of one year or both. I have been notified by DFO that the child support worker who is handling my case will contact the noncustodial parent of my child ren and set up a meeting with him/her to attempt to reach an agreement to pay child support. The amount of child support to be paid will be based on his/her income. If I have any information that DFO should know prior to this meeting such as the noncustodial parents income employer etc. I must contact the child support worker immediately. I have assigned to DFO any and all rights and interests in any cause of action past present or future that I or the child ren included in this application may have against any parent failing to provide for the support of the minor child ren A non-refundable fee of 25 will be charged as an application fee and to recover the costs of any services performed for applicants who are not receiving public assistance Temporary Assistance for Needy Families TANF or Supplemental Nutritional Assistance Program SNAP. Social Security Number Birth Date Email Address Mailing Address Home Address Employer Name and Address Telephone Number Home Work Cell Place of Divorce Separated Never Married-Paternity Established Other Relationship Explain NONCUSTODIAL PARENT NCP INFORMATION Name Ht Wt Hair Eyes Scars/Tattoos Alias City County and State of Birth Country if not USA Multiple Jobs Health Ins Children Covered Were you ever married to the other parent Yes No Date of Marriage / Divorced Yes No Divorce Date Excluded from paternity. I authorize the Mississippi Department of Human Services Division of Field Operations DFO to perform the following Locate the noncustodial parent Establish the legal paternity of my child ren Get a legal order for child support including medical insurance for the child ren or get an amendment to the child support order if one already exists Enforce the child support order by any way permitted by law Collect and distribute child support payments according to Federal guidelines and the laws of the State of Mississippi Disclose my circumstances in pleadings or other documents filed in a proceeding to enforce/determine child support for my child ren. .

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