470 0188 Form – Fill Out and Use This PDF

Child Support Recovery Unit

APPLICATION FOR NONASSISTANCE SUPPORT SERVICES

INSTRUCTIONS

In order to get help from the Child Support Recovery Unit (Unit), you must:

•Fill out and return this application

•Pay the required fee

The child support program helps:

•Establish paternity

•Establish child support and medical support (Medical support could include health insurance or a cash amount to help pay for medical expenses.)

•Collect regular support payments

•Enforce medical support

The amount we collect depends upon the payor’s income and assets. We pick the enforcement actions for your case.

To serve you better, we need your help. Please:

1.Send us copies of all papers that establish paternity or support.

2.Send us a clerk of court record of all support payments made on the case.

3.Immediately tell us in writing or by telephone:

a)If you change your name, address, or phone number.

b)If you hire a private attorney.

c)If you decide you no longer want our services.

d)If your support order is modified.

e)If you get new information about the other parent’s location or employment.

We use many sources to help us find payors and their employers. But you may find this out before we do. Please tell us by writing or calling your local office, listed on page 10. If you need assistance finding the local office that serves you, call the child support automated information line at 1-888-229-9223 (toll free nationwide).

Iowa law says support payments have to be sent to our Collection Services Center (CSC). We send the payor a form explaining how to make payments.

Here is how we apply payments to your case:

•First, we pay any current support due for the month. Whether support is for the current month is based on when the employer withheld it, or when CSC gets it, depending on the source. If there is money left over, we pay the newest balance due first.

•Once we send the payee at least $500 in a year, and if the children have never gotten public assistance, Iowa law requires the payee to pay an annual fee of $25. We take this $25 fee from the support payments.

•If the children get public assistance, the payee assigns the support to the state for that period. This means we pay the support we collect to the state. The state keeps the lesser of the public assistance paid or the amount of assigned support.

•After the payee goes off public assistance, we pay:

OAny current support to the payee.

OAny past-due amounts due the payee.

OAny past due amount due the state.

•We only pay future support when:

OThere are no past due amounts.

OThe payment is for more than current support and is not from income withholding.

OThe payor asks us to if the payment is from income withholding.

•If there is money due the state, the payee may review collections kept by the state through the automated information line or on our web site.

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PAYOR INFORMATION

Payor’s legal name: (Last, First, Middle)							Payor’s maiden name or aliases:
							Social security number:
Payor’s mailing address:							Date of birth:				Age:
							Home phone number:
							Race:			Height:
Home address if different from mailing address:							Weight:			Sex:
							Hair Color:			Eye Color:
Payor’s cell phone number:							Scars, marks, tattoos, etc.:
Payor’s social media usernames or URL’s:
Payor’s email address:
Date and place payee last lived with payor:
Is the payor employed? Yes	____	No	_____				Payor’s most recent employer:
							Employer’s phone number:
Has the payor provided any support? Yes				_______			No	________

If yes, describe below:

Type of support		Amount			How often received
Money
Provided food & clothing
Pays payee’s monthly bills
Vehicle owned or driven by payor:		Make:		Color:		Year:
Model:		License number:		State:
Unions or fraternal organizations:
Credit accounts/bank accounts:
Reason for payor’s absence:
Divorce____ Never married___	In Jail___ In Prison___		Legal separation___ Out of the country____
If in the Military, list what branch:
	PAYOR’S INCOME AND RESOURCES
If known, list the type and amount of income the payor has:
Type of income		Amount			How often received
Wages (includes self employed)
Unemployment benefits
Social security or disability
Veterans benefits
Other

Tell us about any property the payor owns:

PARENTS, RELATIVES, AND/OR FRIENDS OF PAYOR

Tell us other ways to locate or contact the payor:

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MEDICAL SUPPORT INFORMATION

Is any health insurance available to you or your child?				Yes	_____			No	_____
If yes, who is enrolled? Self		Self and Child		None
	____		____			_____

Is there a support order that requires that medical support be provided? (Medical support could include health

insurance or a cash amount.) Yes			No
	_______			______

If yes, explain_____________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Is there any health insurance available to the child’s other parent? Yes

____

No

____

Unknown

_____

If yes, who is enrolled? Other parent

______

Other parent and child

_______

Unknown

______

PLEASE COMPLETE THE FOLLOWING HEALTH INSURANCE BENEFITS SECTION.

The date the coverage began: _____________________________________________

Type of coverage (Please check all that apply):

Family Medical _____	HMO ______
Family Dental ______	PPO _______
Individual Medical _____	Vision ______
Individual Dental ______	Other _______

Name of the person who has the policy:________________________________________________________

The person who has the policy is (please check): Payee____ Payor____ Other (specify) _____________

COOPERATION REQUIREMENTS

You must cooperate in the following ways:

A.Come to our office to give us information we need to establish or modify support or paternity.

B.Appear as a witness at judicial or other hearings or proceedings.

C.Complete and sign forms we need.

D.Do other things we need to help establish, modify or enforce support.

E.Pay fees such as process server and annual fees when required.

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CERTIFICATION STATEMENT

NOTE: PLEASE READ CAREFULLY BEFORE SIGNING

My statements and the information I gave in this application are true and correct to the best of my knowledge and belief.

I agree to notify the Unit if I change my address, and give the Unit my new address.

I agree to cooperate with the Unit in the establishment, modification or enforcement of a support obligation. I understand that if I do not cooperate, the Unit may stop services.

I understand that listing Social Security Numbers for my children and myself is voluntary according to 42 USC 402(c)(2)(C). The Unit requests these social security numbers according to 42 USC 654 and 666 and Iowa Code Chapter 252B. As provided by federal statutes at 42 USC 654A(d) and Title IV-D of the Social Security Act, the Unit uses these social security numbers to establish, modify and enforce child support or medical support, or to establish paternity or for other child support program purposes. The numbers may be released to the other parent and to others because of these actions and purposes. The federal Privacy Act, 5 USC 552a note (1) requires the Unit to notify you of the possible disclosure and use of social security numbers.

By signing this application, I agree that the Unit can take any necessary legal action to establish, modify and enforce a child and/or medical support obligation.

I understand that I may ask the Unit to close my case by notifying the Unit of my wish to cancel services.

I understand that the Unit can close my case under 441 Iowa Administrative Code 95.14(252B). If I ask, I may receive a copy of that information. I understand I have the right to ask for a hearing to appeal the closing of my case. If I appeal, I must make a written request within 30 days of the action that I am appealing, to the Department of Human Services-Appeals Section, 5th Floor, 1305 East Walnut, Des Moines, IA 50314-0114.

I understand that if the payee received public assistance (FIP), support collected from the payor’s federal income tax refund applies to the money due the state before the payee receives any.

I understand that the payee is personally liable to return any support the payee received from the Unit in error. This includes money that the Unit must return to the Internal Revenue Service or the Iowa Department of Administrative Services.

I understand that when the Unit accepts this application for services, one of the people with whom I may discuss my case is an attorney who is an employee of the Unit or the Attorney General’s office. None of the services provided to me establish an attorney-client relationship with either the Unit or the attorney. The attorney works for the state of Iowa and represents only the state. By turning in this application, I admit that I understand and accept this condition.

I understand that the Unit keeps information about people who receive child support services, including their address, confidential. However, information may come out as a part of court actions to establish or enforce support. Sometimes the court may order the Unit to release confidential information.

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SUSPENSION, SATISFACTION, AND REINSTATEMENT OF SUPPORT

Parents may jointly ask us to help get a temporary suspension of support. The parents must be reconciled and living in the same household with some or all the children, or one or more children must now live with the payor. If the situation changes within six months, we can ask the court to reinstate the order. Fee: See FEES FOR COURT ACTIONS, above.

INCOME WITHHOLDING

We may enter an order to withhold support payments from the payor’s income. Support may be withheld from wages, other earnings, trust income, unemployment benefits, Social Security benefits, Veteran’s benefits, and worker’s compensation. Fee: There is no charge for this service.

INTERCEPTION OF FEDERAL INCOME TAX REFUNDS

We may take the federal income tax refund of a parent who owes past due support. The amount we take is first applied to past due support assigned to the state before any amount is paid to the payee. Fee: There is no charge for this service.

INTERCEPTION OF STATE INCOME TAX REFUNDS

We may take the state income tax refund of a parent who owes overdue support. Fee: There is no charge for this service.

INTERCEPTION OF FEDERAL PAYMENTS

We may take a payment the federal government owes a person with a past due child support debt. Fee: There is no charge for this service.

PASSPORT SANCTIONS

We may report a payor to the US State Department when the payor owes more than $2,500 in overdue support. This prevents the payor from getting or renewing a passport. Fee: There is no charge for this service.

REFERRAL TO CREDIT AGENCIES

We may report a payor to credit agencies if the payor owes at least $1,000 in past due support. Fee: There is no charge for this service.

CONTEMPT OF COURT

When the payor doesn’t pay support, we may ask the court for an order requiring the payor to show why he/she is not in contempt of court. Fee: See FEES FOR COURT ACTIONS.

INTERNAL REVENUE SERVICE COLLECTION SERVICES

We may send the name of the payor to the Internal Revenue Service so that the IRS may attach real and personal property. The IRS sells the property through public auction to satisfy the support debt. This process may only be used if all other enforcement methods are unsuccessful and the past due support is at least $750. Fee: The IRS charges a fee of $122.50 to the person requesting this service.

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LOCATIONS OF THE IOWA CHILD SUPPORT RECOVERY UNITS

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