Form DHR/CSEA980/980A "Application for Support Enforcement Services" - Maryland

What Is Form DHR/CSEA980/980A?

This is a legal form that was released by the Maryland Department of Human Services - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the Maryland Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DHR/CSEA980/980A by clicking the link below or browse more documents and templates provided by the Maryland Department of Human Services.

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Download Form DHR/CSEA980/980A "Application for Support Enforcement Services" - Maryland

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MARYLAND DEPARTMENT OF HUMAN RESOURCES
Child Support Enforcement Administration
APPLICATION FOR SUPPORT ENFORCEMENT SERVICES
INSTRUCTIONS
Form No.:
DHR/CSEA 980/980A
Form Name: Application for Support Enforcement Services
Purpose:
The purpose of this form is to gather information from the individual applying for child support enforcement services.
Detailed Instructions: Complete Sections I, II, III, IV and V. Child support staff person shall complete Sections VI and VII.
Section I:
Custodial Parent
Provide all information requested. If “Family Violence” is checked, provide corroborating evidence (e.g. police reports) or reason to believe
that the disclosure of such data might result in physical or emotional harm to a custodial parent, noncustodial parent or a child in a case.
NOTE: Corroborating evidence is not required. Indicating family violence will impact the quality of service provided by restricting the
amount of information that can be shared with and obtained from the federal government and other secure resources.
Section II:
Support
Provide all information requested.
Section III:
Noncustodial Parent
Provide most recent information. The DATE after LAST KNOWN ADDRESS refers to the latest date in which the information was known to
be correct. If “Family Violence” is checked, provide corroborating evidence (e.g. police reports) or reason to believe that the disclosure of such
data might result in physical or emotional harm to a custodial parent, noncustodial parent or a child in a case.
NOTE: Corroborating evidence is not required. Indicating family violence will impact the quality of service provided by restricting the
amount of information that can be shared with and obtained from the federal government and other secure resources.
Section IV:
Health Insurance
If either parent has individual health insurance coverage or health insurance coverage for the child(ren), check the appropriate box and enter
information about the insurance company, if known.
Section V:
Signature
After completing the required information, the form must be signed by the applicant.
Section VI:
Services Required
The child support staff person shall check the appropriate box for the type of service required.
Section VII: Validation
The child support staff person shall check the appropriate box, sign the form, enter his/her title and the date of the validation
Note: Some applicants will complete more than one application. In those instances, check $25.00 application fee paid” on one form only.
Check “Fee previously paid” on all others.
Distribution: Application for Support Enforcement Services, must be retained and copies distributed. The instructions for retention and distribution of
form 980-980A are provided below.
1 copy to applicant
1 copy to fiscal, if accompanied by fee
1 copy to prosecutor, if necessary.
Original – Case folder
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DHR/CSEA 980/980A (Revised 10/13) Page 1 of 6
MARYLAND DEPARTMENT OF HUMAN RESOURCES
Child Support Enforcement Administration
APPLICATION FOR SUPPORT ENFORCEMENT SERVICES
INSTRUCTIONS
Form No.:
DHR/CSEA 980/980A
Form Name: Application for Support Enforcement Services
Purpose:
The purpose of this form is to gather information from the individual applying for child support enforcement services.
Detailed Instructions: Complete Sections I, II, III, IV and V. Child support staff person shall complete Sections VI and VII.
Section I:
Custodial Parent
Provide all information requested. If “Family Violence” is checked, provide corroborating evidence (e.g. police reports) or reason to believe
that the disclosure of such data might result in physical or emotional harm to a custodial parent, noncustodial parent or a child in a case.
NOTE: Corroborating evidence is not required. Indicating family violence will impact the quality of service provided by restricting the
amount of information that can be shared with and obtained from the federal government and other secure resources.
Section II:
Support
Provide all information requested.
Section III:
Noncustodial Parent
Provide most recent information. The DATE after LAST KNOWN ADDRESS refers to the latest date in which the information was known to
be correct. If “Family Violence” is checked, provide corroborating evidence (e.g. police reports) or reason to believe that the disclosure of such
data might result in physical or emotional harm to a custodial parent, noncustodial parent or a child in a case.
NOTE: Corroborating evidence is not required. Indicating family violence will impact the quality of service provided by restricting the
amount of information that can be shared with and obtained from the federal government and other secure resources.
Section IV:
Health Insurance
If either parent has individual health insurance coverage or health insurance coverage for the child(ren), check the appropriate box and enter
information about the insurance company, if known.
Section V:
Signature
After completing the required information, the form must be signed by the applicant.
Section VI:
Services Required
The child support staff person shall check the appropriate box for the type of service required.
Section VII: Validation
The child support staff person shall check the appropriate box, sign the form, enter his/her title and the date of the validation
Note: Some applicants will complete more than one application. In those instances, check $25.00 application fee paid” on one form only.
Check “Fee previously paid” on all others.
Distribution: Application for Support Enforcement Services, must be retained and copies distributed. The instructions for retention and distribution of
form 980-980A are provided below.
1 copy to applicant
1 copy to fiscal, if accompanied by fee
1 copy to prosecutor, if necessary.
Original – Case folder
(NEXT PAGE)
DHR/CSEA 980/980A (Revised 10/13) Page 1 of 6
MARYLAND DEPARTMENT OF HUMAN RESOURCES
Child Support Enforcement Administration
APPLICATION FOR SUPPORT ENFORCEMENT SERVICES
Support enforcement services include:
Searching for the other parent
Collecting support payments
Legally establishing paternity
Enforcing the court order
Reviewing and modifying a court order, periodically
Establishing a court order for child support and health insurance coverage
Please complete this form carefully and provide as much detailed information as possible. Legibly print the answers on this form. If you are the custodial parent, complete a separate form
for each noncustodial parent from whom you want support. The accuracy of the information you provide may affect how your case is handled. If you do not understand any questions on
this form, please call 1-800-332-6347.
SECTION I: CUSTODIAL PARTY – (PARTY OR RELATIVE WITH WHOM THE CHILDREN
RESIDE)
__________________________________________ _________________________ ________________________
Full legal name
(First, Middle, Last)
Maiden Name
Alias Name
__________________________________________ _____ __________ __________________ ____________
Apt #
Address
Sex
Date of birth
Race
______________________________________________________ _____________________________________
City
State
Zip Code
Social Security number
___________________ _____________________ __________________________ ________________________
Cell phone
Home phone
Business phone
E-mail/web address
__________________________________________ __________________________________________________
Employer’s name
Employer’s address
__________________________________________ ____________________________ ____________________
Name of nearest relative
Relationship
Phone number
_____________________________________________________________________________________________
Address
City
State
Zip Code
Family Violence: I believe that disclosure of my address or other identifying information might result in physical or emotional harm to me or my child.
(Please see instructions on page 1)
I believe the other party (parent) will cooperate with this office to establish, modify, and enforce a support order.
I think the alleged father will request genetic testing.
State Where
Conception
Relationship
Birthplace
SECTION II: SUPPORT – CHILDREN:
Occurred
(City, State)
Sex
Race
to you
Name
Social Security
Date of
Number
Birth
1)___________________ _____________ __________ __________ _____ _____ __________ ___________
2)___________________ _____________ __________ __________ _____ _____ __________ ___________
3)___________________ _____________ __________ __________ _____ _____ __________ ___________
4)___________________ _____________ __________ __________ _____ _____ __________ ___________
5)___________________ _____________ __________ __________ _____ _____ __________ ___________
1. If you are the mother of the child(ren), were you married to a man other than the noncustodial parent at the
time the child(ren) were conceived or born?
o Yes
o No
2. What is the relationship between the mother and father of the child(ren)?
o Never married o Currently married o Legally Separated o Divorced o Other ________________
3. Date married:__________ State where married:_________ Date/place divorced/separated:_________________
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DHR/CSEA 980/980A (Revised 10/13) Page 2 of 6
4. If separated, have divorce proceedings been started by a private attorney and/or is court action currently
o Yes
o No
pending?
If yes, please list name, address, and phone number of the attorney and the County and State in which court
action is pending: __________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
o Yes
o No
Is child support included in this action?
5. If the parents were not married: Has paternity been established for the child(ren)?
o Yes
o No
Was paternity established by Affidavit?
Yes
No
If yes, which State? ______________________
6.
If yes, which State? _____________________
7.
Was paternity established by Court Order?
o Yes
o No
8. If you answered YES to question #6 or 7, please list the children for whom paternity has been established or an
Affidavit of Parentage signed:
___________________________________________________________________________________________
9. Do you have a court order for child support from this noncustodial parent?
o Yes
o No
10. If you answered yes to #4, 5, 6, 7, 8 or 9 above, show where paternity/support was ordered. Include a copy of the
order with your application.
__________________________ _________________ _________________________ ____________________
County
State
Court docket #
Date of order
11. Does the noncustodial parent pay support?
o Yes
o No
12. If yes or sometimes, to whom does the noncustodial parent pay support?
o To you
o To a child support agency
o Other _____________________________________________
13. Name and address of the child support agency: ____________________________________________________
__________________________________________________________________________________________
14. Date support last paid: _____________________ Amount: $________________________________________
o Yes o No
15. Is support paid by a military allotment?
16. Have you ever received Temporary Cash Assistance (TCA, formerly AFDC or “welfare”), Medical Assistance,
o Yes
o No
or previously applied for Child Support Services?
If yes, list the County and State: ______________________ Date of last TCA check if applicable: __________
17. Date of NCP’s last contact with applicant or child: _____________________
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DHR/CSEA 980/980A (Revised 10/13) Page 3 of 6
SECTION III – NONCUSTODIAL PARTY (PARTY WITH WHOM THE CHILDREN DO NOT RESIDE)
_____________________________________ ______________ ______________ ___________ ____________
Maiden Name
Alias/Nickname Home phone Business phone
Full legal name
(First, Middle, Last)
_______________________ __________ _____ _______________________ __________________________
Cell phone number
Date of birth
Race
Sex
Social Security number
______________________________________ ______ _____________________ _____ _____________ ______
Address (or Last known address)
Apt #
City
State
Zip Code
Date
_____________________________________________________________________________________________________________________________
If you are the Noncustodial Party, please check the appropriate box[es]:
Family Violence: I believe that disclosure of my address or other identifying information might result in physical or emotional harm to me or
my child. (Please see instuctions on page 1)
I believe the other party (parent) will cooperate with this office to establish, modify, and enforce a support order.
(There may be a fee for genetic testing.)
I would like genetic testing.
_____________________________________________________________________________________________________________________________
_________________________________________ ____________ ____________ _____________ ___________
E-mail/web address
Eyes
Hair
Height
Weight
Identification marks:____________________________________________________________________________
_________________________________ ______________________ ________________________ ___________
Driver’s license number
Automobile tag number
Automobile make/model
Year
1. Current or prior military service dates: From _________ to _________ What branch? _________________
2. Has the noncustodial parent ever been in jail? o Yes o No Dates: From ___________ to ____________
Name of jail: ________________________ Address: _____________________________________________
3. Name of noncustodial parent’s father: ___________________________________________________________
_____________________________________________________________________________________________
Phone number
Address
City
State
Zip Code
4. Name of noncustodial parent’s mother: __________________________________ Maiden name: ___________
________________________________________________________________________________ ____________
Address
City
State
Zip Code
Phone number
5. Name of nearest noncustodial relative: ______________________________________Relationship _________
______________________________________________________________________________ ____________
Phone number
Address
City
State
Zip Code
6. Noncustodial parent’s place of birth: _____________________________________________________________
7. Noncustodial parent’s current or last known employer: ______________________________________________
Employer’s address: __________________________________________________________________________
Phone number: ____________________ Employment History – Dates: From ___________ to _____________
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DHR/CSEA 980/980A (Revised 10/13) Page 4 of 6
8. Does noncustodial parent receive a pension, disability benefits, social security, or have any other source of
income?
o Yes
o No
o Unknown
Income amount: $ _____________ From what source: _____________________________________________
o Yes o No If yes, please specify: _____________
9. Is noncustodial parent a member of a Union/Local?
10. Does noncustodial parent have a license, certificate, registration or permit that is necessary to practice or work
in a particular business, occupation or profession? o Yes o No If yes, what type? ___________________
o Yes
o No
o Unknown
11. Does the noncustodial parent have other child support cases?
If so , what state or states? __________________________________________________________________
12. Do you have a photograph of the noncustodial parent? o Yes o No If yes, please attach photograph.
SECTION IV – HEALTH INSURANCE
1. Do the children currently have heath insurance? o Yes
o No
o Unknown
2. Insurance provided by:
Father:
Mother:
Other (State, Step parent, Grandparent, etc.):
Name:___________________ Relationship:___________
3. Insurance company:
Name: ________________________________
Address: _________________________________________
Phone Number: ___________________________
Policy number: __________________________________
Group number: _______________ Effective date: _____________
Policy expiration date: _____________
4. Is insurance available through an employer for
Father:
Yes
No
Mother:
Yes
No
5. Name and address of employer providing the health insurance. _______________________________________
_____________________________________________________________________________________________
6. Name of child(ren) covered by the health insurance. ________________________________________________
_____________________________________________________________________________________________
7. Type of coverage provided: (Check appropriate coverage)
o HMO
o PPO/PPN
o POS
o Pharmacy
o Dental
o Vision
o Hospital services
o Physician services
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DHR/CSEA 980/980A (Revised 10/13) Page 5 of 6