DSS Form 2719-4 "Change of Custodial Parent's Application for Child Support" - South Carolina

What Is DSS Form 2719-4?

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

Form Details:

  • Released on September 1, 2007;
  • The latest edition provided by the South Carolina Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSS Form 2719-4 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 2719-4 "Change of Custodial Parent's Application for Child Support" - South Carolina

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South Carolina Department of Social Services
CHANGE OF CUSTODIAL PARENT’S APPLICATION FOR CHILD SUPPORT
Employee’s USERID:
Date Application Requested:
Date Application Mailed:
Case Number:
Date Application Received:
Authorization and Assignment of Rights
1. I do hereby apply to the South Carolina Department of Social Services (SCDSS), Child Support Enforcement Division (CSED)
for Non-TANF services under Title IV-D of the Social Security Act. I hereby authorize the SCDSS to act in my behalf in
enforcing and collecting my child support.
2. In consideration for legal services and other assistance provided in obtaining child support, I hereby voluntarily assign and
transfer unto SCDSS all the support rights, including those past, present and future, which I have against
for the support of
Noncustodial Parent (Individual Paying the Child Support)
Child/Children
for whom I have care and custody.
Child/Children
3. The assignment is subject to the terms and conditions of Title IV-D of the Social Security Act, as amended (42 USC 654(6)).
4. I understand that when this application for services is accepted, one of the people with whom I may discuss my case is an
attorney who is an employee of the CSED. None of the services provided to me establish an attorney-client relationship with
the CSED. The attorney is employed by the state of South Carolina and remains an attorney for the state. Submission of this
application constitutes my acknowledgment and acceptance of this condition.
5. I request that the CSED obtain and/or enforce medical support from the NCP if it is available at a reasonable cost:
Yes
No, I have satisfactory insurance.
6. I do hereby attest under penalties of perjury that the above information is true and complete to the best of my knowledge and
belief and is given for the purpose of receiving services under Title IV-D of the Social Security Act. I have read all application
instructions and agree to the conditions and fees as outlined in this application.
7. I understand, that as part of the 2005 Deficit Reduction Act passed by Congress, beginning October 1, 2007, all applicants who
have never received public assistance (AFDC/TANF) will be charged a $25.00 fee each year after $500.00 in child support has
been collected and paid out. This fee will not be charged until at least $500.00 is collected and paid out. If you have more than
one eligible case, the fee will be charged on each case meeting the $500.00 threshold.
8. Permission to Recoup An Overpayment: Upon written notification of payment error from Child Support Enforcement Division,
I agree to allow CSED to retain up to 10 percent of any future child support payments to correct any overpayment I received.
Yes
No
Applicant’s Signature
Date
Witness’ Signature
Date
Witness’ Signature
Date
Custodial Parent Information
(Person With Whom Child Or Children Is/Are Living)
Your Name: Last:
First:
Middle:
Suffix:
Maiden Name:
SSN:
Race:
Sex:
Current Marital Status:
Place of Birth: City:
State:
Birthdate:
Residential Address:
Home Telephone:
City:
State:
Zip Code:
Mailing Address: c/o Last:
First:
Middle:
Suffix:
Address:
City:
State:
Zip Code:
Your Employer’s Name:
Work Telephone:
Address:
City:
State:
Zip Code:
Work Start Time:
Work End Time:
If Currently Married, Spouse’s Name/Address:
Place of Marriage: City:
State:
Date of Marriage:
If not currently married, have you ever been married?
Yes
No If yes, provide:
Name of Former Spouse:
Date and Place of Marriage:
If Divorced, Date and Place of Divorce:
Relationship of Custodial Parent to Child:
DSS Form 2719-4 (SEP 07) Replaces DSS Form 2719.
SEE BACK FOR INSTRUCTIONS
South Carolina Department of Social Services
CHANGE OF CUSTODIAL PARENT’S APPLICATION FOR CHILD SUPPORT
Employee’s USERID:
Date Application Requested:
Date Application Mailed:
Case Number:
Date Application Received:
Authorization and Assignment of Rights
1. I do hereby apply to the South Carolina Department of Social Services (SCDSS), Child Support Enforcement Division (CSED)
for Non-TANF services under Title IV-D of the Social Security Act. I hereby authorize the SCDSS to act in my behalf in
enforcing and collecting my child support.
2. In consideration for legal services and other assistance provided in obtaining child support, I hereby voluntarily assign and
transfer unto SCDSS all the support rights, including those past, present and future, which I have against
for the support of
Noncustodial Parent (Individual Paying the Child Support)
Child/Children
for whom I have care and custody.
Child/Children
3. The assignment is subject to the terms and conditions of Title IV-D of the Social Security Act, as amended (42 USC 654(6)).
4. I understand that when this application for services is accepted, one of the people with whom I may discuss my case is an
attorney who is an employee of the CSED. None of the services provided to me establish an attorney-client relationship with
the CSED. The attorney is employed by the state of South Carolina and remains an attorney for the state. Submission of this
application constitutes my acknowledgment and acceptance of this condition.
5. I request that the CSED obtain and/or enforce medical support from the NCP if it is available at a reasonable cost:
Yes
No, I have satisfactory insurance.
6. I do hereby attest under penalties of perjury that the above information is true and complete to the best of my knowledge and
belief and is given for the purpose of receiving services under Title IV-D of the Social Security Act. I have read all application
instructions and agree to the conditions and fees as outlined in this application.
7. I understand, that as part of the 2005 Deficit Reduction Act passed by Congress, beginning October 1, 2007, all applicants who
have never received public assistance (AFDC/TANF) will be charged a $25.00 fee each year after $500.00 in child support has
been collected and paid out. This fee will not be charged until at least $500.00 is collected and paid out. If you have more than
one eligible case, the fee will be charged on each case meeting the $500.00 threshold.
8. Permission to Recoup An Overpayment: Upon written notification of payment error from Child Support Enforcement Division,
I agree to allow CSED to retain up to 10 percent of any future child support payments to correct any overpayment I received.
Yes
No
Applicant’s Signature
Date
Witness’ Signature
Date
Witness’ Signature
Date
Custodial Parent Information
(Person With Whom Child Or Children Is/Are Living)
Your Name: Last:
First:
Middle:
Suffix:
Maiden Name:
SSN:
Race:
Sex:
Current Marital Status:
Place of Birth: City:
State:
Birthdate:
Residential Address:
Home Telephone:
City:
State:
Zip Code:
Mailing Address: c/o Last:
First:
Middle:
Suffix:
Address:
City:
State:
Zip Code:
Your Employer’s Name:
Work Telephone:
Address:
City:
State:
Zip Code:
Work Start Time:
Work End Time:
If Currently Married, Spouse’s Name/Address:
Place of Marriage: City:
State:
Date of Marriage:
If not currently married, have you ever been married?
Yes
No If yes, provide:
Name of Former Spouse:
Date and Place of Marriage:
If Divorced, Date and Place of Divorce:
Relationship of Custodial Parent to Child:
DSS Form 2719-4 (SEP 07) Replaces DSS Form 2719.
SEE BACK FOR INSTRUCTIONS
INSTRUCTIONS FOR DSS FORM 2719-4
The South Carolina Department of Social Services, Child Support Enforcement Division (CSED), offers child support
services to non-TANF applicants who have physical custody of a minor child. To obtain our services, an applicant must:
• Fully complete the application and sign where indicated. Two witnesses must also sign the application where
indicated. If necessary information is not provided or the witnesses’ signatures are not affixed, the
application will be returned to the applicant.
• Cooperate fully with CSED in providing information necessary to proceed with the case.
• Send the completed application to:
South Carolina Department of Social Services
Child Support Enforcement Division, Region IV
2120 Jody Street, Suite 4
Florence, South Carolina 29501
DSS Form 2719-4 (SEP 07)
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