Form Dcf F Dwsc12181 PDF Details

The Department of Children and Families (DCF) is responsible for the welfare of children and families in the state of Florida. One important part of their work is providing financial assistance to families in need. The DCF website offers a number of resources for those seeking help, including the Form Dcf F Dwsc12181. This form can be used to apply for benefits such as Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamps. Families who are eligible may receive financial assistance to help them meet their basic needs. In this blog post, we will provide an overview of the Form Dcf F Dwsc12181, including what information is required and how to submit it. We will also take a look at some common benefits that may be available to qualifying families. If you are interested in applying for benefits through the DCF, this post will provide a helpful starting point.

QuestionAnswer
Form NameForm Dcf F Dwsc12181
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdcf_f_dwsc12181 what to do with tn child support stale dated check form

Form Preview Example

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Family and Economic Security

REQUEST FOR RE-ISSUANCE OF A STALE-DATED CHECK

PLEASE SEE INSTRUCTIONS ON THE BACK OF THIS PAGE

Mail to:

Bureau of Child Support

P.O. Box 7935

Madison WI 53707-7935

Information provided on this form (including any attachments) may be shared with others only for the purpose(s) of administration of the child support program and other related programs [Wis. Statutes, s.49.83]

The provision of your Social Security number is mandatory under Section 466(a) (42U.S.C.666(a)). Your Social Security number will be used for identification purposes. If you do not provide your Social Security number, your application will be denied.

Payee Name on the Original Check

Claimant (Your) Telephone Number

 

(

)

 

 

 

 

Payee Social Security Number

KIDS Personal Identification Number (PIN) if known

 

 

 

 

Payee Name for the New Check

 

 

 

 

 

 

 

Street Address of the Person Making This Claim

 

 

 

 

 

 

 

City

State

 

Zip Code

 

 

 

 

Signatures Must be Notarized

 

*Signature of person making the claim for re-issuance of a

If more than one person, signature of other person making the

 

stale-dated check

 

 

claim for re-issuance of a stale-dated check

 

 

 

 

 

 

 

 

Print Name

 

 

Print Name

 

 

 

 

 

 

 

 

 

 

Notarization is Required

 

 

Place Seal Here

 

 

 

Subscribed and affirmed to me

 

 

 

 

 

 

This __________ day of _______________, __________

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Public, State of ____________________________

 

 

 

 

 

 

My Commission (is permanent) _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

OR

 

 

Official Use

 

 

 

 

 

Fund

Agency

 

 

Expires ________________________________________

 

 

 

 

 

 

 

 

 

Person Handling

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Request Approved

 

 

 

 

 

 

Yes

No

 

Send this document to the address provided in the upper left-hand corner of this document. Check replacement will take 3 weeks.

*If the payee is deceased, the person making the claim on behalf of the payee’s estate should complete this form as completely as possible and attach a letter explaining that they are acting on behalf of the estate. Attach notarized copies of your appointment or authorization to act in this capacity.

DCF-F-DWSC12181 (R. 05/2012)

INSTRUCTIONS FOR COMPLETION OF A

REQUEST FOR RE-ISSUANCE OF A STALE-DATED CHECK

Payee Name on the Original Check

Please insert the name of the person named on the check you are asking a re-issuance for. This may be you or someone else.

Claimant (Your) Telephone Number

Please insert YOUR telephone number here. You are the claimant. This may be the person named on the check or someone else.

Payee Social Security Number

This is the social security number of the person named on the check. This may be you or someone else. The provision of your Social Security number is mandatory under Section 466(a) (42U.S.C.666(a)). Your Social Security number will be used for identification purposes. If you do not provide your Social Security number, your application will be denied.

KIDS Personal Identification Number (PIN) if Known

This is the PIN (as assigned in the KIDS child support system) of the person for whom the check was written, the person named on the check.

Check Number if Known

If you have the check or the check number, write it in this box. The check number is written boldly on the check. If more than one check, fill out the attached Check List form.

Street Address of the Person Making This Claim

This is where the check will be mailed if your claim is approved. This may be the address of the person named on the check or someone else. If it is not the address of the person named on the check, please attach an explanation.

City, State, and Zip Code

Please provide these as part of the street address above.

Signature of Person Making the Claim for Re-Issuance of a Stale-Dated Check

This is the signature of the person making the claim for the check. It may or may not be the person named on the check. It is the signature that must be notarized. If it is not the person named on the check, please attach an explanation. If the person making this claim is acting on behalf of the payee’s estate, then you must attach notarized copies of your authorization to act in this capacity. If the form is not properly notarized, it cannot be processed.

If more than one person, please provide the signature of the other person making a claim for re-issuance of a stale-dated check

If more than one person is making the claim for re-issuance of a stale-dated check (For example: if the claim is part of an estate that is jointly administered), please provide the second person’s signature here. This signature must also be notarized.

Print Name

Please carefully and clearly print your name(s) in the boxes provided.

DCF is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact (608) 266-9909 or (800) 947-3529 WTRS TTY (Toll Free).