Dss Form 1216 PDF Details

DSS Form 1216 is a form used to report changes in your family's income or household composition. This form is important because it helps the government ensure that all families receive the correct amount of benefits, based on their current circumstances. If you have any changes in your family's income or composition, be sure to fill out and submit a DSS Form 1216 as soon as possible. Failure to do so may result in lost benefits for your family. For more information on DSS Form 1216, or any other related topics, please visit our website. Thank you for your time.

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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This document will need you to type in some specific details; to ensure accuracy, please be sure to take heed of the subsequent suggestions:

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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