Application for Child Support Collection Services

Please answer the following questions as completely as possible. If you have only part of the information requested, please fill in those blanks. We understand that your contact with your obligor may be limited. Please submit a separate worksheet for each child support collection case that you need help with. Once you complete this form, you can submit it directly to us. Be sure to enter a phone number and a good time to call you. We'll get back to you within three business days.

1. What is your name?

2. What is your email address?

3. What is your address?

Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

4. Please list your phone numbers, with area codes.

 

5. What is the best time and location to reach you by telephone?

 

 

6. Do you have a court order for child support? 
yes no

 

If your answer to this question was no, we are unable to help you with your case. You would need to consult an attorney.

7. Where did you get your court order?

Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

 

8. What year did you get your court order? 

 

 

9. How much was the monthly amount of child support in this order? 

 

 

10. Was the amount of child support ever changed?  yes no

If yes, what was the changed amount?

 

11. What is the approximate amount of past due support?  

 

12. Please list the dates of birth of the children involved in this child support case. (MM/DD/YY)

Child 1		Child 2
Child 3		Child 4
Child 5		Child 6

13. What is the obligor's name?

14. What is the most recent address you have for the obligor?

Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

15. What is the obligor's date of birth?

 

16. What is the obligor's social security number?

 

17. What was the obligor's last known occupation or employer?

 

18. Did you ever request assistance collecting child support from one of the following? (Select all that apply.)

Private Attorney
County Domestic Relations Department
Office of the Attorney General
Private Collection Agency

 

19. Did you ever receive cash benefits from the state government? (AFDC/TANF/Welfare)
yes no

20. Were any of your children on Medicaid? yes no

21. If you answered yes to either of the two previous questions, has any state debt been repaid? yes no

22. How did you first hear of Child Support - 2 Collect?

TV commercial Internet Link Newspaper Ad Yellow Pages Personal Referral

 

23. Are there any questions you would like to ask us?