Form Ldss 4882C – Fill Out and Use This PDF

CIN ____________

WMS Line Number ________

First

Middle

Last

Suffix

Name of Child

Date of

Month/Day/Year

SSN

-

-

ITIN

-

-

Birth

____ / ____ / ____

 Male

Name of

Mother: First

Middle

Last

 Female

Gender

Biological

 Unborn

Father: First

Middle

Last

Parent

Due Date ____ / ____ / ____

Relationship of the

 Parent  Stepparent

 Putative Father

NCP/PF to the Child

Parents’ Marital

Was the mother married to the father or stepfather of the child at the time of the child’s birth?  Yes

 No  Unknown

If “Yes,” go to the “Order of Support Information” questions below.

Status

If “No” or “Unknown,” go to the “Paternity Establishment” questions below.

Please note that if paternity was not established for the child, a paternity affidavit must be completed.

Was paternity established?  Yes – Go to the “Paternity Establishment” questions below. You do not need to complete

the “State of Jurisdiction” questions below.

 No – Go to the “State of Jurisdiction” questions below.

 Unknown – Go to the “State of Jurisdiction” questions below.

Paternity

How was paternity established?

In what county, state, and country was paternity

Establishment

 Established in Court on _______ / ________ / ________

established?

Name of Court _________________________________

County _________________________________________

State ___________________________________________

 Acknowledgment of Paternity on ______ / _____ / _____

Country _________________________________________

Where was the child conceived?

State _____________________________

Country ________________________

State of

Did the PF provide prenatal expenses or support for the child?

 Yes

 No

 Unknown

Jurisdiction

Did the PF reside with the child in New York State?

 Yes

 No

 Unknown

Does the child reside in New York State as the result of acts or directives of the PF?

 Yes

 No

 Unknown

Is there an order of support for this child?  Yes

 No  Unknown

Is health insurance ordered?

If “Yes,” what is the date of the order?

_________ / _________ / ________

 Yes  No

 Unknown

Order of Support

Information

Obligation Amount

$ ________  Weekly  Every two weeks  Monthly  Twice per month

(Complete only if

 Other ____________________________________________

different for this

child)

Court that Issued

 Family Court

County/State/Country

Court Docket or Index Number

the Order

 Supreme Court

 Other

Does the child have health care coverage?  Yes

 No

 Unknown

If “Yes,” identify the type of coverage:

 Private – Go to “Health Insurance Benefits” questions below.

 Public – Go to “Public Health Care Coverage” questions below.

 Unknown – Go to “Section B – Supporting Documentation” on page A-7.

Health Care

Who provides the child’s private health care coverage?

 CP  Guardian  NCP/PF  Stepparent  Unknown  Other ________________________

Coverage

Information

Health Insurance

Name of Health Insurance Carrier

Policy Number

Group Number

(Complete only if

Benefits

different for this

child)

No.

Street

Floor/Apt./Suite

City

State

Zip

Public Health Care

Indicate the type of public health care coverage:

Coverage

 Medicaid  Family Health Plus  CHPlus  Other ____________________

Parent’s CHPlus monthly contribution: $ ________

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childsupport.ny.gov

The Commissioner or Designee must complete this section on behalf of the social services

Foster Care

district (SSD) or the Office of Children and Family Services (OCFS) Commissioner for a

Referral

child in Foster Care placement.

Name of Child

First

Middle

Last

Suffix

Case Number

Case Status

Date of Referral

Case Information

 Opening

 Reopening

 Changes or Updates

_______ / _______ / ________

Category

What is the claiming category?

 IV-E Foster Care

 Non-IV-E Foster Care

 Voluntary

Placement Date

Cost of Care

Type of Placement

 Court Ordered

_________ / _________ / _________

$ ___________ Per:  Day  Week  Month  Year

Name of Agency,

County

Agency Name

Type of Facility

Facility, Foster

Boarding Home

Placement Address

No.

Street

Floor/Apt./Suite

City

State

Zip

Is an adoption subsidy received on behalf of the child?

Does the subsidy include Medicaid?

Subsidy

 Yes

 No

 Yes

 No

Information

Subsidy Amount and When It Is Paid

$ ________________ Per:

 Week

 Month

 Year

Name

Phone Number

Case Manager

(

)

Ext.

 I am applying for Child Support Services as the Commissioner or Designee and this is a

Application for

Foster Care referral.

Child Support

Services

Signature of Commissioner/Designee ________________________________________________

Date ____________________________________________________________________________________________

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childsupport.ny.gov