Dss Form 1216 PDF Details

The DSS 1216 form, issued by the South Carolina Department of Social Services, plays a crucial role in the Family Assistance Program, particularly in the domain of child support and voluntary financial contributions. Designed to create an organized method for individuals to report and document voluntary child support payments or contributions, it serves both as a record-keeping tool and a communication medium between the contributor and the County Department of Social Services. This form requires detailed information about the support provided to the child or children in question, asking for specifics such as the amount of support, frequency, duration, and the recipient of these payments. Additionally, it addresses whether the contributor directly pays bills for the child, has medical or hospital insurance for them, and other contributions that may not fall under typical child support categories. The form is designed to be filled out by the person providing support, requiring a signature to verify the accuracy of the information provided. By facilitating a structured way to report these contributions, the DSS 1216 form ensures transparency and accountability in voluntary family support arrangements, making it a pivotal document for caregivers and social service workers alike.

QuestionAnswer
Form NameDss Form 1216
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbi, dcs single case agreement for foster child, DEC, grandparent

Form Preview Example

 

 

South Carolina Department of Social Services

 

 

Family Assistance Program

 

 

VOLUNTARY CHILD SUPPORT/CONTRIBUTION FORM

To:

 

 

Recipient’s Name:

 

Address:

 

Case No.:

 

 

 

 

 

Case Name:

 

Please complete the items checked below concerning the above named individual, sign and return to: County Department of Social Services.

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Worker’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

I. Child Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Are you the father/mother/grandparent of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

?

Yes

No

2.

Are you giving any money for support of this child/these children?

Yes

No

 

 

 

 

 

 

 

If yes, how much and how often?

$

 

 

 

 

 

 

 

 

 

 

Weekly

Bi-weekly

Monthly

Varies

 

3.

Are you giving support money on a regular basis?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

How long have you been giving support money?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

To whom do you pay this money? (Check one)

 

Recipient

 

Clerk of Court: Which county?

 

 

 

 

 

 

 

Other: Who?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Do you pay any bills directly for the recipient?

 

Yes

 

 

 

No If so, what?

 

 

 

 

 

 

 

 

 

 

 

 

7.

How much did you give during the past two months?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

Amount Given

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

Amount Given

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

8.

Do you have medical/hospital insurance on this child/these children?

Yes

 

 

No

 

 

 

 

 

 

 

If yes, tell us the company’s name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Do you have a driver’s license?

 

Yes

No

 

 

If yes, print your license number:

 

 

 

 

 

 

 

10.

What is your social security number?

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

11.Where do you work? Company Name: Company’s Address: Company’s Telephone No.:

Your Printed Name:

Your Signature:

Telephone No.:

DSS Form 1216 (NOV 09) Edition of DEC 88 is obsolete.

II. Contributions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Do you give any money directly to the recipient other than child support?

Yes

 

No

 

2.

For what purpose is the money given?

 

 

 

 

 

 

 

 

3.

Do you pay any bills directly for the recipient? Yes

No

 

 

 

 

 

 

If so, what?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

How much did you give during the past two months?

 

 

 

 

 

 

 

 

 

Date

 

 

Amount Given

 

 

Date

 

 

Amount Given

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

5.

How long have you been giving this money?

 

 

 

 

 

 

 

 

6.

Is this money a gift?

Yes

No Is this money a loan?

Yes

No

 

 

 

7.

If a loan, when do you expect to be repaid?

 

 

 

 

 

 

 

 

 

Your Printed Name:

Your Signature:

Telephone No.:

DSS Form 1216 (NOV 09)

PAGE 2

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1. Firstly, while filling out the NOV, begin with the area that features the subsequent blanks:

Step # 1 of submitting grandparent

2. Once your current task is complete, take the next step – fill out all of these fields - cidcidcidcid Do you pay any bills, Date, Amount Given, Date, Amount Given, cidcidcidcid Do you have, If yes tell us the companys name, cidcidcidcid Do you have a, Companys Address, Companys Telephone No, Your Printed Name, Your Signature, and Telephone No with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing part 2 in grandparent

3. In this part, examine II Contributions cidcidcidcid Do, If so what, cidcidcidcid How much did you, Date, Amount Given, Date, Amount Given, cidcidcidcid How long have you, If a loan when do you expect to be, Is this money a gift cidcidcidcid, Your Printed Name, Your Signature, and Telephone No. Each of these need to be filled out with greatest attention to detail.

How to prepare grandparent step 3

In terms of Telephone No and Is this money a gift cidcidcidcid, be certain that you take a second look here. These could be the most significant fields in this file.

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