Wa Form Referral PDF Details

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QuestionAnswer
Form NameWa Form Referral
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswa form referral, wa dshs referral, child support referrals fillable, form support referral

Form Preview Example

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):

 

 

 

 

 

 

 

 

 

 

Name (First/Middle/Last):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Names Used:

 

 

 

 

 

 

 

 

 

 

 

Other Names Used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box or Street Address:

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

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):

 

 

 

 

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):

 

 

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?

 

 

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last-Known Employer's Name:

 

 

 

 

 

 

Last-Known Employer's Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's City:

 

 

 

State:

 

ZIP Code:

 

 

Employer's City:

 

 

 

State:

 

ZIP Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's Telephone Number:

 

 

 

 

 

 

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?

 

 

No

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?

 

 

 

 

 

 

 

 

 

 

 

 

No

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?

No

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?

No

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?

No

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?

No

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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