Mi Child Support Services Form PDF Details

The Mi Child Support Services form, formally recognized as the IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL, is a comprehensive document used by the Michigan Department of Health and Human Services Office of Child Support (OCS) to facilitate the application or referral for child support services within Michigan. This form is meticulously structured to collect detailed information about the custodial parent or caretaker, the non-custodial parent or alleged father, and any other relevant caretakers, including their personal, employment, and contact information. It ensures the efficient processing and management of child support cases by gathering essential data such as the child(ren)'s health care coverage, the marital status of the parents, and specific directives for handling overpayments or erroneous disbursements through the Michigan State Disbursement Unit (MiSDU). Additionally, the form outlines the legal requirements and expectations from applicants, including acknowledgements regarding the voluntary provision of social security numbers as mandated by the Social Security Act for the purpose of paternity establishment and the enforcement of child support obligations. Applicants are also informed about the implications of not providing information, which may affect their eligibility for certain benefits. This form acts as a critical liaison between custodial parents, caretakers, and the OCS, ensuring that all parties are informed about their rights and responsibilities in the child support process, and underscores Michigan's efforts to support the welfare of children through proper financial support mechanisms.

QuestionAnswer
Form NameMi Child Support Services Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshow to mi child support services, michigan form support, mi child support, child services application

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IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL

Michigan Department of Health and Human Services

Office of Child Support (OCS)

Please check your relationship to the children for whom you are applying for child support services:

FOR OFFICE USE ONLY

Date Requested

Date Provided

Date Filed

 

Program

 

748

 

 

 

 

 

 

 

 

 

Provided

 

 

 

 

 

 

 

 

 

 

IV-D Case No.

MDHHS Case No.

 

County

District

 

Unit

 

Worker

 

 

 

 

 

 

 

 

 

 

Custodial Parent

Non-Custodial Parent or Alleged Father

Other Caretaker, Specify

•Custodial Parent - Complete all sections of the form, enter information about you in Section A.

•Non-Custodial Parent or Alleged Father – Complete all sections of the form except Section F, enter information about you in Section B.

•Other Caretaker - Complete all sections of the form, enter information about you in Section A. Complete information about each parent who is not in the home in Section B. (Please complete a separate application for each parent who is not in the home.)

A. INFORMATION ABOUT THE CUSTODIAL PARENT/CARETAKER OF THE CHILD

1.

Name (First, Middle, Last, Suffix)

 

 

Maiden Name (If applicable)

2. Birthdate

 

 

3. Social Security No.

 

 

 

 

 

 

 

 

 

 

 

4.

Home Address (P.O. Box No., No. and Street)

City

 

 

State

 

Zip Code

 

County

 

 

 

 

 

 

 

 

5.

Home Phone No.

6. Work Phone No.

 

7. Cell Phone No.

 

 

(

)

(

)

 

 

 

(

)

 

 

 

B. INFORMATION ABOUT THE PARENT WHO IS NOT IN THE HOME

8. Parent’s Name (First, Middle, Last, Suffix)

 

 

 

Maiden Name (If applicable)

 

 

9. Social Security No.

10. Birthdate

11. Age

 

12. Sex (M or F)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Home Address (P.O. Box No., No. and Street)

Current

Last Known

City

 

State

 

Zip Code

14.

Home Phone No.

 

15. Cell Phone No.

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

(

)

16. Weight

 

17. Height

 

18. Hair Color

 

 

 

 

19.

Eye Color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Birthplace (City, State)

21. Driver’s License Number

22. Car (Make, Model and Year)

23. License Plate Number

24. Race or Ethnic Code:

 

 

 

 

 

 

 

 

 

 

 

 

25. Any Visual Marks or Scars?

 

 

 

 

Alaskan Native

 

 

Hispanic

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian

 

Multiracial – More than one racial-ethnic group

 

 

Middle Eastern

 

 

 

 

 

 

 

 

 

Asian or Pacific Islander

 

Black, not of Hispanic origin

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26. First Employer Name

Current

Last Known

27. Employer Address (P.O. Box No., No. and Street)

City

 

 

State

Zip Code

28. Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

29. Second Employer Name

Current

Last Known

30. Employer Address (P.O. Box No., No. and Street)

City

 

 

State

Zip Code

31. Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

C. MARITAL STATUS INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32a. Has the mother ever married?

 

b. Name of Spouse

 

 

 

 

c. Date Married

 

d. Place (City, County, State)

 

 

 

 

 

No

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33a. Is the mother

 

 

 

b. Date

 

c. Court Order Exist?

 

d. Court Order No.

e. Where (City, County, State)

 

 

 

 

 

Separated

Legally Separated >>

 

 

No

 

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34a. Is the mother

 

 

 

b. Date

 

c. Court Order Exist?

 

d. Court Order No.

e. Where (City, County, State)

 

 

 

 

 

Divorced

 

Divorce filed >>

 

 

 

No

 

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please attach a copy of all court orders pertaining to the family members listed on this application, including Personal Protection Orders and guardianship papers.

DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word

1

D. INFORMATION ABOUT CHILD(REN)

Child One (Please include separate pages if more than three children)

35a. Child’s Full Name (First, Middle, Last, Suffix)

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

e. City, County & State of Birth

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

Date

City

County

State

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Date

City

County

State

 

 

 

 

 

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

Yes

No

36a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

PPO PPOM

Traditional

d. Policy or Group No.

Child Two

37a. Child’s Full Name (First, Middle, Last, Suffix)

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

e. City, County & State of Birth

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

Date

City

County

State

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Date

City

County

 

State

 

 

 

 

 

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

Yes

No

38a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

PPO PPOM

Traditional

d. Policy or Group No.

Child Three

39a. Child’s Full Name (First, Middle, Last, Suffix)

 

 

 

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

 

 

 

 

e. City, County & State of Birth

 

 

 

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

 

 

Date

 

City

 

County

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Date

City

County

State

 

 

 

 

 

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

Yes

No

40a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

 

 

 

PPO

PPOM

Traditional

 

 

 

 

 

DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word

d. Policy or Group No.

2

E. GENERAL INFORMATION

41.

I believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or the child.

Yes

No

 

 

42.

I have received or I am currently receiving benefits from the Family Independence Program (FIP) or I have received past benefits from Aid to Dependent Children (ADC).

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, when?

 

 

 

Where?

 

 

 

 

 

 

 

 

 

 

 

43.

I have received or I am currently receiving Medicaid (MA).

Yes

No

 

 

 

 

 

If yes, when?

 

 

 

Where?

 

 

 

 

 

 

 

 

 

 

 

44.

I am currently receiving: Food Assistance Program (FAP)

Yes

No

Child Development and Care (CDC)

Yes

No

 

 

 

 

 

 

 

 

 

 

F. ACKNOWLEDGEMENT FOR CUSTODIAL PARENTS AND CARETAKERS

The Michigan Office of Child Support (OCS) processes child support payments through the Michigan State Disbursement Unit (MiSDU), which is part of the Michigan Department of Health and Human Services (MDHHS). The MiSDU receipts and distributes payments by direct deposit to a bank account, to a debit card, or by paper check.

If I am sent money in error or overpaid, the MiSDU will take all the necessary steps to correct errors in the processing of my child support payments. By checking the “yes” box below, I give OCS permission to withhold an incremental amount specified below from future child support payments owed to me. To revoke my consent, I must notify the Friend of the Court office. Failure to check “yes” has no effect on my eligibility for IV-D Child Support services through OCS.

Yes, (circle one) 10%

25% or 50%

Failure to choose a percentage will result in a default amount of 25%.

 

No, please contact me before you attempt to recover an amount from my support payments.

 

 

 

G. ACKNOWLEDGEMENT FOR ALL APPLICANTS

 

 

 

 

 

I request child support services available under Title IV-D of the Social Security Act.

Authorities:

 

All Services

 

 

45 CFR 302.33 Completion: Application is voluntary for non-

Locate Only (for custodial parents and caretakers only)

assistance applicants.

 

Medical Support Only (for Medicaid cases only)

R 400.3009 MAC and R 400.5008 MAC Failure to complete may result in

 

 

 

I understand that disclosure of my Social Security number is mandated by the Social Security Act, 42 USC 666(a)(13), in order that

loss of benefits from Child Development and Care (CDC) and the Food

Michigan’s child support program may provide services related to the establishment of paternity and the establishment, modification

Assistance Program (FAP). Current FAP and CDC recipients are not

and enforcement of child support obligations. I understand that I must cooperate in taking support action to ensure that my child

required to sign the form.

support case remains open. I declare that the information provided above is true and correct to the best of my knowledge and agree

 

to report changes in my circumstances that may affect support action in my case.

42 USC 654(29) Failure to provide information may result in loss of

I certify that I have received a copy of DHS Publication 748, “Understanding Child Support, A Handbook for Parents.”

Family Independence Program (FIP) benefits for all family members and

loss of Medicaid (MA) for all adult members.

 

 

 

 

 

 

Applicant’s Signature (Signature is Required)

Date

 

 

 

 

 

Applicant’s Printed Name

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to an MDHHS office in your area.

This institution is an equal opportunity provider.

Return completed application to:

Michigan Office of Child Support

Central Functions Unit

P.O. Box 30744

Lansing, MI 48909

DHS-1201 (Rev. 6-15) Previous edition may be used. MS Word

3

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2. Your next stage would be to fill out these blanks: Asian or Pacific Islander, Black not of Hispanic origin, Other, First Employer Name, Current, Last Known, Employer Address PO Box No No and, City, Second Employer Name, Current, Last Known, Employer Address PO Box No No and, City, State, and State.

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F ACKNOWLEDGEMENT FOR CUSTODIAL, If yes when, and Where in dhs 1201d

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