Form Ldss 2521 – Fill Out and Use This PDF

LDSS-2521 (Rev. 3/04)

FOR AGENCY USE ONLY

APPLICATION FOR

NAME OF REFERRING OFFICIAL

TELEPHONE NO.

CHILD SUPPORT SERVICES

UNIT

DATE OF REFERRAL

APPLICATION TYPE

NYS OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

 Original

 Supplemental

A

NAME (Last, First, M.I)

RELATIONSHIP TO CHILDREN

SOC. SEC. NO.

DATE OF BIRTH

Applicant/

Petitioner

ADDRESS–Legal Residence (Street, City, State, Zip)

TELEPHONE NUMBER

HOME

(Include Area Code)

SUPPORT COLLECTION

I have applied for or am in

 I have not applied for nor

(N/P = No Phone)

BUSINESS

UNIT APPLICATION

receipt of

am I in receipt of

ONLY

 HR  ADC  MA

HR/ADC/MA

B

NAME (Last, First, M.I.)

RELATIONSHIP TO APPLICANT

SOC. SEC. NO.

DATE OF BIRTH

ADDRESS–Legal Residence (Street, City, State, Zip) Current or Last Known

TELEPHONE NUMBER

HOME

(Include Area Code)

AbsentParent/

EMPLOYER’S NAME/ADDRESS (Current or Last Known)

(N/P = No Phone)

BUSINESS

Respondent

PLACE OF BIRTH

MOTHER’S MAIDEN NAME

FATHER’S FULL NAME

DATE OF DESERTION

C

NAME (Last, First, M.I.)

DATE OF BIRTH

NAME (Last, First, M.I.)

DATE OF BIRTH

Child. Subject of

Application

D

 File Search (location)

 Child Support Enforcement

DATE OF COURT ORDER

DOCKET NO.

 Paternity Establishment

 Medical Support Enforcement

 Child Support Establishment

 Field Investigation–Child Support*

Services

Requested Applicant/ Petitioner

 Medical Support Establishment

 Field Investigation–Medical Support*

COURT

 Child Support Collection

 Legal Representative–Child Support*

 Medical Support Collection

 Legal Representation–Medical Support*

* Right to Recovery MUST Be Signed in the presence of a IV-D Unit Staff Member, and Notarized to Be Eligible for Field Investigation of Legal Services

E

AFFIRMATION–I hereby apply pursuant to Social Services Law § 111-g and 111-h for child support services under Title IV-D of the Social Security Act

Affirmation

as amended. I subscribe and affirm under penalty of perjury that this application is

accompanying document have been examined by me and to the best of my knowledge

made for the sole purpose(s) of obtaining assistance in establishing paternity and/or

SIGNATURE

DATE

obtaining child support from an individual who is (or may be) legally responsible for the

support of dependent children; and that statements made in this application or

and belief are true and correct.

X

F

COMPLETE THIS SECTION ONLY IF FIELD INVESTIGATION/LEGAL REPRESENTATION IS REQUESTED

I assign to the ____________________ Department of Social Services and New York State the title to and right to receive up to 25% of each child

support payment to be received by me on behalf of the children listed above until such time that DSS is reimbursed for actual costs incurred in

providing the necessary service(s) I requested.

If child support payments are made payable through the Support Collection Unit (S.C.U.) I authorize the S.C.U. to pay the

____________________________ Department of Social Services the amounts assigned above.

I understand that if I do not reimburse the ____________________________ Department of Social Services and New York State for these costs out of

RecoverytoRight

(Supplement)

child support payments received by me, they may initiate a civil proceeding, the total costs for which I will be responsible to pay.

X

SIGNATURE

DATE

State of

SS:

County of

On the ______ day of ___________________ , 20_____, _________________________________________________ , to me known to be the individual

described in and who executed the foregoing instrument and acknowledged that he executed the same.

X

NOTARY PUBLIC

DATE

FOR AGENCY USE ONLY

APPROVED

APPLICATION REVIEW

DENIED