Wa Form Referral – Fill Out and Use This PDF

The Wa Referral form, utilized by the State of Washington's Department of Social and Health Services Division of Child Support (DCS), is a crucial document for enforcing child support as outlined in Title IV-D of the Social Security Act. It collects detailed information about the parents, their children, and the support sought to ensure that child support enforcement measures can be appropriately applied. To take the first step in initiating or managing child support enforcement, consider filling out the Wa Referral form by clicking the button below.

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Wa Form Referral PDF Details

In the landscape of child support enforcement, the Washington State Department of Social and Health Services' Division of Child Support (DCS) plays a pivotal role, predominantly through tools like the Child Support Referral form. This detailed form is designed to capture essential information for child support enforcement purposes, aligning with the mandates of Title IV-D of the Social Security Act. It requires comprehensive data about the parents of the child or children in question, including their names, contact information, social security numbers, employers, and even physical characteristics. Furthermore, it delves into the living arrangement of the children, querying if the noncustodial parent has ever lived with or financially supported the children in Washington State, and if not, it seeks information about the current guardian. The form doesn't stop there; it also gathers specifics about the children for whom support is being sought, including their birth data, tribal affiliations, and any existing child support orders. Additionally, it captures marriage details of the parents, any public assistance received, and the declaration of the informant to provide updated information as circumstances change. By submitting this form, individuals agree to communicate any change in information that could affect the collection of child support, affirming their statements under penalty of perjury—a testament to the form's role in the systematic pursuit of child support enforcement.

Question	Answer
Form Name	Wa Form Referral
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	wa form referral, wa dshs referral, child support referrals fillable, form support referral

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STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

DIVISION OF CHILD SUPPORT (DCS)

Child Support Referral

The Division of Child Support (DCS) will use your personal information and social security number for child support enforcement purposes as defined in Title IV-D of the Social Security Act.

A.Information About the Children's Parents

Mother of Children

Father of Children

Name (First/Middle/Last):

Other Names Used:

P.O. Box or Street Address:

City:

State:

ZIP Code:

City:

State:

ZIP Code:

Home Phone:

Message Phone:

Cell Phone:

Home Phone:

Message Phone:

Cell Phone:

(

)

(

)

(

)

(

)

(

)

(

)

E-mail Address:

Social Security Number:

Date of Birth (Month/Day/Year):

Social Security Number:

Date of Birth (Month/Day/Year):

Place of Birth (City/County/State/Country):

Race:

Height:

Weight:

Hair Color:

Eye Color:

Race:

Height:

Weight:

Hair Color:

Eye Color:

Native Language (If correspondence needed in other than English):

Tribal Affiliation (if applicable):

Lives on an Indian Reservation?

Tribal Affiliation (if applicable):

Lives on an Indian Reservation?

Yes

Last-Known Employer's Name:

Employer's P.O. Box or Street Address:

Employer's City:

State:

ZIP Code:

Employer's City:

State:

ZIP Code:

Employer's Telephone Number:

(

)

(

)

Mother's Father's Name:

Mother's Mother's Maiden Name:

Father's Father's Name:

Father's Mother's Maiden Name

B. The Children's Residence

The children listed on page 2 live with:

Mother

Father

Other (specify):

Did the noncustodial parent ever live with or provide support for the children in Washington State?

Yes

If yes, when?

C. If the Children Do Not Live With the Mother or Father, Complete This Section

Your Name:

Your P.O. Box or Street Address:

Your Social Security Number:

Your Date of Birth:

Your City:

Your State:

Your ZIP Code:

Your Relationship to the Children:

Home Phone:

Message Phone:

Cell Phone:

(

)

(

)

(

)

Tribal Affiliation (if applicable):

Lives on an Indian Reservation?

Yes

FG VER: (1.4)

CHILD SUPPORT REFERRAL

DSHS 14-057 (REV. 04/2010)

Page 1

D.Information About the Children for Whom You Want Child Support

List only the children of the parents listed on page 1 that live in your home. Use a continuation sheet if needed.

First Child's Name (First/Middle/Last):					Sex:	Social Security Number	Did the father sign a paternity
							affidavit?	No	Yes
Date of Birth (Month/Day/Year):		Place of Birth (City/County/State/Country):					Tribal Affiliation (if applicable)

Did the mother become pregnant with this child				If no, then where (County/State):
in Washington State?	No		Yes

Is there a support order for

this child?

Yes

If yes, date of order (Month/Day/Year): If yes, place order entered (County/State/Tribe):

Second Child's Name (First/Middle/Last):					Sex:	Social Security Number	Did the father sign a paternity
							affidavit?	No	Yes

Date of Birth (Month/Day/Year):		Place of Birth (City/County/State/Country):					Tribal Affiliation (if applicable)

Did the mother become pregnant with this child				If no, then where (County/State):
in Washington State?	No		Yes

Is there a support order for

this child?

Yes

If yes, date of order (Month/Day/Year): If yes, place order entered (County/State/Tribe):

Third Child's Name (First/Middle/Last):					Sex:	Social Security Number	Did the father sign a paternity
							affidavit?	No	Yes
Date of Birth (Month/Day/Year):		Place of Birth (City/County/State/Country):					Tribal Affiliation (if applicable)

Did the mother become pregnant with this child				If no, then where (County/State):
in Washington State?	No		Yes

Is there a support order for

this child?

Yes

If yes, date of order (Month/Day/Year): If yes, place order entered (County/State/Tribe):

E.Marriage Information for the Parents of the Children Listed Above

Date Married (Month/Day/Year):	Place Married (County/State):

Date Divorced (Month/Day/Year):	Place Divorced (County/State):

Date Separated (Month/Day/Year):	Place Separated (County/State):

F.Public Assistance and Support Payment Information

Have you or the children listed above ever received public assistance from a state or Indian Tribe?

Yes

If yes, where (Counties/States/Tribes):

If yes, when (Months/Years):

If there is a child support order(s) for the children listed above, how much total support did the noncustodial parent pay

to you for the children (do not include support owed to a state or Indian Tribe)?				$	.
Dates received support: (start)		(end)	.	Attach copies of all support orders.

	G.	Declaration

I agree to tell the DCS immediately, in writing, of any new or changed information that relates to collecting support from the parent responsible for paying support.

I certify or declare under penalty of perjury, under the laws of the state of Washington, that the foregoing is true and correct.

Signed at

, Washington.

Signature:

Date:

No person because of race, color, national origin, creed, religion, sex, age, or disability, shall be discriminated against in employment, services, or any aspect of the program's activities. This form is available in alternative formats upon request

FG VER: (1.4)

CHILD SUPPORT REFERRAL	Page 2
DSHS 14-057 (REV. 04/2010)

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