IV-D Child Support Case Study

1540 Words7 Pages
IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL Michigan Department of Human Services (DHS) – Office of Child Support (OCS) Please check your relationship to the children for whom you are applying for child support services: • • • Date Requested IV-D Case No. Date Provided DHS Case No. FOR OFFICE USE ONLY Date Filed County Program District Unit 748 Provided 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,…show more content…
Child’s Full Name (First, Middle, Last, Suffix) e. City, County & State of Birth g. When and where did the mother become pregnant? Date City County State Yes No b. Birthdate c. Social Security Number f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)? 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 38a. Policy Holder’s Name City County b. Health Care Company Name (Non-Medicaid) c. Coverage Type PPO PPOM…show more content…
Policy or Group No. Traditional d. Sex (M or F) Child Three 39a. Child’s Full Name (First, Middle, Last, Suffix) e. City, County & State of Birth g. When and where did the mother become pregnant? Date City County State Yes No b. Birthdate c. Social Security Number f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)? 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 40a. Policy Holder’s Name City County b. Health Care Company Name (Non-Medicaid) c. Coverage Type PPO PPOM State CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back) d. Policy or Group No. Traditional DHS-1201 (Rev. 11-09) Previous edition may be used. MS Word 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

More about IV-D Child Support Case Study

Open Document