Georgia department of human services

Doc File 3,215.50 KByte,



| |State of Georgia Local Office Stamp |

|[pic] |Department of Human Services |

| |Division of Child Support Services |

APPLICANT INSTRUCTIONS

Thank you for applying for child support services. To offer Same Day Services (SDS), please provide detailed information to help us assist in processing your application. If you receive TANF/Medicaid services, please call the DCSS Contact Center for further assistance (number listed below).

Applicant must provide at least one form of photo identification from the list below:

• Valid driver’s license;

• Any other international government, federal government, state government and local government-issued picture/photo ID including a Green Car or Visa;

• Valid Passport

Applicants MUST provide:

▪ Current income information (i.e. check stubs, W-2’s, or Tax Statements for past 3 years with 1099s if self employed and a completed financial affidavit);

▪ Social Security cards for all children listed in the application (if available);

▪ Birth certificates for all children born OUTSIDE of Georgia;

▪ Marriage license (Note: In the absence of a license, a sworn statement from the applicant attesting their marital status at the time of the child’s(ren) conception & birth can be used);

▪ Signatures on all pages and notarize forms where required;

▪ Proof of physical custody of a minor child or dependent child;

▪ Verification of school enrollment, status, grade level and anticipated graduation date if the child(ren) is 18 and is still a full-time high school student and the court order addresses child support beyond the age of 18, if applicable;

▪ A photocopy of all support orders that exist (Final Divorce Decree, Separation or Settlement Agreement, Child Support Order entered by any state or foreign country, Modification of Support Order, Contempt Order, Juvenile Court Order and/or Temporary Order). Exception: A certified copy of the most recent order setting the support obligation is required if the order must be registered for enforcement in another state or foreign jurisdiction, before DCSS can process a UIFSA action;

▪ Receipts/verification of medical, vision, dental, life insurance, deductibles and co-pays, if applicable;

▪ Extraordinary educational expense information for tuition, room & board, fees, books, if applicable; and

▪ Child rearing expenses for music/art lessons, travel, band, clubs, and athletics, if applicable.

▪ Authorization Agreement for Direct Deposit of Child Support Payments if direct deposit is being requested and a voided check or savings account deposit slip.

Note: Please call the DCSS Contact Center toll-free at 1-877-423-4746 if:

• You speak another language other than English in your home and need assistance,

• You have a disability and need assistance or accommodations to visit our office; or

• You are deaf or hearing impaired and need the assistance.

If you are a TTY (text telephone) user you may contact our office through the Georgia Relay Service at 7-1-1

Note: If possible, please make copies of important information and your entire application before visiting our office to retain for your records.

Applicant Rights and Responsibilities

I understand that:

• The Division of Child Support Services (DCSS) has the authority under federal and state law to take any legal action that is necessary to establish paternity and to establish, modify and/or enforce an obligation for child support including medical support. DCSS does not guarantee that efforts on my behalf will be successful as actions taken by DCSS may be subject to the discretion of the judge;

• DCSS may use an attorney to establish, enforce and/or modify my child support order. There is no attorney-client relationship between me and the attorney, as the attorney represents the State. I understand that the attorney does not handle legal issues such as legitimation, custody or visitation; therefore, I must seek my own private attorney regarding these issues;

• DCSS has provided me with a HIPAA Notice of Privacy Practices. The notice includes an explanation of how medical information related to my application for services may be used by DCSS, as well as my right to have access to this medical information. I understand that DCSS will not share any information unless I provide a written authorization requesting information;

• DCSS will not release any confidential, personal information to any third parties without my prior written authorization to release such information;

• DCSS does not discriminate on the basis of race, color, national origin, sex, age, religion, political beliefs or disability. Should I have concerns about my case, I may file a formal complaint with the local office manager that will result in an internal management review;

• When applying for services as a payee, I must have legal or physical custody of a minor child. In the event that the custody of the child changes, the ordered child support may be redirected to the new custodian;

• I must notify DCSS of any changes to my name, address, phone number(s) or any other information that is needed to properly manage and/or enforce my case, including but not limited to, notifying DCSS that I have applied for Temporary Assistance For Needy Families (TANF) benefits. I understand that failure to keep information up to date may affect DCSS ability to distribute payments in a timely manner;

• I must notify DCSS if I have an active child support case with any other state agency, private attorney or a private collection agency for the child (ren) listed on the application;

• I agree to submit myself and/or the child (ren) to genetic testing, as it relates to establishing paternity, if needed. Genetic test results will not be provided without prior written authorization to release such information;

• A $25.00 non-refundable application fee is required when applying for services unless the child(ren) or I receive Temporary Assistance for Needy Families (TANF) or Family Medical Assistance (Medicaid). The fee will be required if only the child(ren) receive Medicaid or I re-apply for services after requesting case closure or if my case is closed by DCSS due to my non-cooperation;

• A $25 Annual Maintenance Fee will be charged to each case where an applicant has never received TANF and for whom the State has collected at least $500.00 of support. My portion of this fee will be taken from the amount of child support collected on behalf of the children;

• Child support payments must be sent to the Family Support Registry and that I should not accept direct payments from the Non-Custodial Parent (NCP). If I accept payments from the NCP DCSS may close my case for non-cooperation;

• Upon written notification from DCSS, my case may be closed if I fail to cooperate. Prior to case closure, I must repay any outstanding fees and/or overpayments that are owed at the time and repay any expenses incurred on my behalf. If my case is closed due to severe non-cooperation, I will not be able to reopen my case or reapply for services for a minimum period of six (6) months from the date my case was last closed;

• I agree that overpayments of the support ordered amount will be applied first to the past due amounts and then may be held by DCSS for future payments;

• If I should receive payments distributed to me in error, I will be notified in writing to establish a Recoupment Repayment Installment Plan with DCSS. I understand that my failure to respond timely to the third and “Final Notice” from DCSS shall serve as my permission for DCSS to recoup payments from any future child support due to me;

• My case will not be eligible for closure until all fees and/or overpayments are paid in full;

• If I request case closure during a legal proceeding to establish a support order, I understand that I will be responsible for any fees and costs incurred by DCSS, including but not limited to court costs and service fees, before my case will be closed;

• Federal law authorizes DCSS to charge an individual who has applied for child support services and who has never or is no longer receiving TANF assistance a fee for the offset of state and federal taxes. In the event that an offset is received, an administrative fee of $12.00 per state offset and $15 per federal offset may be assessed to my case;

• I may receive correspondence from DCSS electronically. To ensure confidentiality of such correspondence, I understand that it is my responsibility to provide a secure and active email address;

• I may obtain my case and payment information by calling the Contact Center at 1-877-423-4746, or I may view my case information on the Customer Service Online website at .

I have received and read all program information describing available services, fees, as well as my rights and responsibilities. I have the right to ask questions before I submit my application. My signature on this document authorizes the Division of Child Support Services to provide necessary and appropriate services on my behalf.

_______________________________________________________

Name of Applicant (Please Print Clearly)

_______________________________________________________ _________________________________________ ____________

Signature of Applicant Witness Date

Applicant’s Email address is: (Please Print Clearly) ____________________________________________________

Application for Services

|PLEASE CHECK ONE |

|I AM THE: Custodial parent [ ] Noncustodial parent [ ] Nonparent Custodian [ ] Alleged Father [ ] |

|TYPE OF SERVICE REQUESTED (check which applies) |

|All services available for support [ ] |

|TANF HISTORY (check all that apply): |

|I have never received TANF benefits [ ] I currently receive TANF benefits [ ] I currently receive Medicaid Only [ ] |

|Formerly on TANF [ ]: Received from ______________ to _______________ |

|CUSTODIAL PARENT/NONPARENT CUSTODIAN INFORMATION |

|Name: |

| Last First Middle Maiden Name |

|Social Security Number: |Date of Birth: |Place of Birth: |

|Sex: Male [ ] Female [ ] |Race: |Have you ever had a child support case in another state? [ ] Yes [ ] No |

|Marital Status: Single [ ] Married [ ] Separated [ ] |If married, current spouse’s name:______________________________________ |

|Divorced [ ] Divorced on: ___/___/___ |Date of Marriage: ___/___/___ |

|Home Address: |

| Street Address City, County State, Zip |

|Mailing Address: |

| Street Address / P.O. Box City, State Zip |

|May be contacted at work? [ ] Yes [ ] No |E-Mail Address: |

|Work Phone: |Home Phone: |Cellular Phone: |

|Is the custodial parent/nonparent custodian in the military? [ ] Yes [ ] No If so, name the Military Branch: [ ] Retired Military |

| |

|INSURANCE INFORMATION FOR CUSTODIAL PARENT |

|Do you currently have health insurance? [ ] Yes [ ] No |If yes, is the minor child you are applying for child support services covered in this |

| |Policy? [ ] Yes [ ] No |

|Insurance Co. Name: |Phone No.: |

|Policy No.: |Group#: |

|DOMESTIC VIOLENCE |

|Have you ever been a victim of domestic violence? [ ] Yes [ ] No |

|Has the child(ren) you are requesting services for ever been a victim any physical or emotional harm? [ ] Yes [ ] No |

|If yes to either or both of the above questions, describe your concerns and/or attach supporting documentation to support your claim on the application. |

|Under Georgia Law, O.C.G.A. §19-11-30 and §19-11-131, the DCSS will not release any information that would place you or your children at risk of physical or emotional |

|harm. In such instances, a Family Violence Indicator will be activated on your child support case. |

|Your case will then be coded to ensure that no information is released to any other state or foreign jurisdiction that may place you or your child(ren) at risk. |

|CHILDREN FOR WHOM YOU NEED SERVICES |

|Name |

|(Last, First, Middle) |

|PAYMENT INSTRUCTIONS FOR CUSTODIAL PARENT / CUSTODIAN |

| |

|Unless a request is made for direct deposit a debit card will be provided for child support payments. If direct deposit is selected, a separate form and voided check / |

|deposit slip are required. |

|ALLEGED FATHER / NONCUSTODIAL PARENT INFORMATION |

|Name: |

| Last First Middle Maiden Name |

|Aliases or nicknames: | |

|Social Security Number: |Date of Birth or Age: |Place of Birth: |

|Sex: Male [ ] Female [ ] |

|Marital Status: Single [ ] Married [ ] Separated [ ] |If married, current spouse’s name:______________________________________ |

|Divorced [ ] Divorced on: ___/___/___ |Date of Marriage: ___/___/___ |

|Eye color: |Hair color: |Weight: |Height: |Race: |

|Mailing Address: |

|[ ] Owns this or other property |

| Street Address City, County State, Zip |

|Is home address [ ]Current or [ ]Last known |Phone Number(s): |

|Other Possible Address: |

| Street Address City, State, Zip |

|Driver’s License #: State: |

|ALLEGED FATHER / NONCUSTODIAL PARENT EMPLOYMENT |

|[ ] Employed [ ]Unemployed [ ] Self-employed |Type of Business: |Usual Occupation: |

|Current or Last Known Employer: |Phone No.: |

|Dates of employment: ____/____/____ to ____/____/____ | |

|Supervisor: |Job title: |

|Address: |

|Street Address City County State Zip |

|Gross income: $ per |Paid: [ ]Weekly [ ]Bi-weekly [ ]Monthly [ ]Semi-monthly |

| |Attach Pay stubs, if possible |

|INSURANCE INFORMATION FOR ALLEGEDFATHER / NONCUSTODIAL PARENT |

|Does “alleged” father/NCP currently have health insurance? [ ] Yes [ ] No |If yes, is the minor child you are applying for child support services |

| |covered in this Policy? [ ] Yes [ ] No |

|Insurance Co. Name: |Phone No.: |

|Policy No.: |

|Monthly Premium: $_________________________ |Portion Paid for Child: $________________________ |

|OTHER INCOME SOURCES /RESOURCES |

|Federal Benefits Received: [ ] Social Security [ ] Postal [ ]RR Retirement [ ]Civil Service [ ] Military [ ] VA [ ] Retirement[_] Receives SSI Receiving |

|Unemployment Benefits? [ ] Yes [ ] No |

|Receiving Pension Plan benefits? [ ] Yes [ ] No If so, from what company? |

|Any professional licenses? [ ] Yes [ ] No If so, what type?: |

|Is the noncustodial parent in the military? [ ] Yes [ ] No If so, name the Military Branch: [ ] Retired Military |

| |

| |

| |

| |

| |

| |

|INCARCERATION HISTORY |

|Has the noncustodial parent been: [ ] in Prison [ ] on Probation or has Probation history |

|If incarcerated please give dates ____/____/____ to ____/____/____ |

|Institution’s name: _____________________________________ |

|Institution’s address or city/state:__________________________________________________________ |

|If on probation or has a probation history please give: |

|Probation history dates ____/____/____ to _____/____/_____ |

|Probation period to end: ___/___/___ |

|Probation / parole officer's name: _________________________ |

|Probation / parole officer's name: _________________________ |

|ALLEGED FATHER / NONCUSTODIAL PARENT FAMILY HISTORY |

|Mother: |Maiden Name: |Phone #: ( ) |

|Date of Birth: |Place of Birth: |Deceased On: Deceased on: |

|Address: |

| Street Address City, State, Zip |

|Father: |Phone No.: |

|Date of Birth: |Place of Birth: |Deceased on: |

|Address: |

| Street Address City, State, Zip |

|Other known Relative: |Relationship: |

|Address: |

| Street Address City, State, Zip |

|Other contact address (friends, etc): |

| Name Street Address City, State, Zip |

|Other contact phone number: |

|Complete this section ONLY if you are NOT the child(ren)’s Parent |

|I, _________________________________________________ am the legal custodian of the child(ren) named above. I obtained legal custody for the child(ren) on / / |

|(proof of guardianship is required). Acceptable legal documents include, but are not limited to, Juvenile Court custody orders, Superior Court custody orders and Probate |

|Court guardianship orders. |

|My relationship to the child(ren) is _______________________. The child(ren) came to live with me on (MM/DD/YY): / / |

|Biological Mother (note if deceased): |

| Name Address City, County, State, State, Zip Date of Birth SSN |

|Biological Father (note if deceased): |

| Name Address City, County, State, State, Zip Date of Birth SSN |

| |

|________________________________________________________ ___________________________ |

|Signature Date |

| |

Under the penalty of perjury, I do hereby swear and affirm that the information I provided on the Application for Child Support Services is accurate and true to the best of my knowledge. I understand that knowingly making false statements and false swearing is punishable under Georgia law by a fine up to $1,000, by imprisonment between one and five years, or both. I do hereby attest to the truthfulness of the information provided.

_______________________________________________________________ _______________________

Applicant Signature Date

|For DCSS Office Use Only: |

|Application Requested Date (required):____/_____/____ Application Provided (date given in person or mailed) (required):___/___/____ |

|Application Provided by (staff’s first and last name required):_______________________________________ |

| |

|(Note: Federal regulations require an application be provided the same day to individuals who make in person requests or within 5 working days of a written or|

|telephone request, see 45CFR §303.2(a)(2)). |

|Date returned to DCSS / / Application Processed Date (required):____/___/______ Processed by (First & Last Name)______________________ $TARS |

|No: ______________________________ Application fee PAID (Y/N): [_ ]; If no, why not?_______________________________________________ |

PERSONAL / FINANCIAL AFFIDAVIT

$TARS Case Number: ____________________________________

Non-Custodial Parent Name: ______________________________

Custodial Parent Name: __________________________________

CUSTODIAL PARENT [ ] NON CUSTODIAL PARENT [ ] NON PARENT CUSTODIAN [ ]

PERSONAL INFORMATION:

Your name: ________________________________________ DOB: ________________ Social Security Number:____________________

Other married names, nicknames, etc: __________________________________________________________________________________

Home address:_____________________________________________________________________________________________________

Street Address City State County Zip

ADOPTION / FOSTER CARE:

[ ] Currently receive [ ] Never received [ ] Reunification / Foster Care Plan

How much monthly? $__________________

YOUR EMPLOYMENT:

[ ] Employed [ ] Unemployed [ ] Self-employed Type of Business:____________________________________________________

Employer: _______________________________________ Job Title:__________________________________________________

Supervisor:_______________________________________ Work Phone No: _____________________________________

Employer address: _________________________________________________________________________________________________

Street Address City State County Zip

Employed from ____/____/____ to ____/____/____ [ ] Union:__________________ Local No:___________________________

GROSS Income: $________ (Attach pay stubs) Pay Frequency: [ ] Weekly; [ ] Bi-weekly; [ ] Monthly; [ ] Semi-monthly

Do you have any Professional licenses: [ ] Yes If so, what type? ___________________ License #:________________________

NAME OF BANK / CREDIT UNION:

_____________________________________ Account Type [ ] Checking [ ] Savings Acct #:_________________________________

_____________________________________ Account Type [ ] Checking [ ] Savings Acct #:_________________________________

YOUR TANF (WELFARE) HISTORY:

[ ] Never on TANF [ ] Currently on TANF [ ] Formerly on TANF [ ] History Unknown

[ ] Receives Medicaid Only; [ ] Receives Food Stamps only; TANF received from ___/___/___ to ___/___/___

PREVIOUS EMPLOYMENT (LAST 3 YRS):

Provide City, State & Employer Name. Complete addresses are not required.

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

EDUCATIONAL HISTORY:

Highest grade level in school you have completed: __________________

Highest degree you have earned: [ ] None [ ] GED [ ] Technical College/AA [ ] College Degree or higher

Last School (High School, Trade, Colleges) attended:

____________________________________________________________________________________

Name Street City State Zip Phone Number

____________________________________________________________________________________

Name Street City State Zip Phone Number

PRE-EXISTING CHILD SUPPORT ORDERS BEING PAID FOR OTHER CHILDREN:

| | | |IS CHILD RECEIVING|AMOUNT BEING PAID |

|COURT NAME AND |INITIAL DATE OF |NAMES AND BIRTHDATES OF CHILDREN |TANF? | |

|COURT CASE NUMBER |ORDER | | |PAYMENT RECORD REQUIRED |

| | | | |$ |

| | | | |$ |

| | | | |$ |

| | | | |$ |

OTHER CHILDREN

|NAME __________________________________________ DOB ___/___/___ |NAME ________________________________ DOB ___/___/___ |

YOUR FINANCIAL SUMMARY

| |Average | |Average |

|Gross Income Source |Monthly |Expense Source |Monthly |

| |Gross Amount| |Gross |

| | | |Amount |

|Salary / Wages (do not include TANF) |$ |Rent or mortgage payment |$ |

|Commissions, fees & tips |$ |Utilities (electric, natural / propane gas, telephone) |$ |

|Self-Employment Income |$ |Child care (proof is required) |$ |

|[Refer to O.C.G.A. §19-6-15 (f)(1)(B) for details] | | | |

| | |Alimony Paid (proof is required) |$ |

|Bonuses |$ |Food |$ |

|Overtime Payments |$ |Medical bills or expenses |$ |

| | |(not covered by insurance) (proof is required) | |

|Severance Pay |$ |Probation / parole fines |$ |

|Recurring income from Pensions or retirement plans |$ |Vehicle payment |$ |

|Interest Income |$ |Clothing |$ |

|Income from dividends |$ |Transportation/Visitation costs (proof is required) |$ |

|Trust income |$ |Child support paid by previous court order |$ |

|Income from annuities |$ |Property taxes |$ |

|Capital Gains |$ |Recreation |$ |

|Social Security Disability or Retirement |$ |Insurance (health) (proof is required) |$ |

|(Do not include SSI or payment for children) | | | |

|Worker's Compensation benefits |$ |Insurance (life) (proof is required) |$ |

|Unemployment Compensation benefits |$ |Insurance (automobile, home) |$ |

|Judgments from Personal Injury or other Civil Cases |$ |Insurance (Dental/Vision) (proof is required) |$ |

|Gifts (cash or other gifts that can be converted to cash) |$ |Bankruptcy |$ |

|Prizes / Lottery winnings |$ |Extraordinary Educational Expenses (i.e., tuition, books,|$ |

| | |room & board) (proof is required) | |

|Alimony & maintenance from persons not on this case |$ | | |

|Assets which are used for support of family |$ |Child’s extraordinary medical expenses |$ |

| | |(co-pays, deductibles) (proof is required) | |

|Fringe Benefits (if significantly reduce living expenses) |$ | | |

|Any other income including Imputed Income: |$ |Special expenses for child rearing (i.e., camp, band, |$ |

|(Do not include means-tested public assistance, such as TANF or Food Stamps) | |music, art, clubs) (proof is required) | |

| | |Other: |$ |

|TOTAL MONTHLY GROSS INCOME: |$ |TOTAL MONTHLY EXPENSES: |$ |

YOUR ASSETS: (Bank accts, bonds, whole life insurance-cash value CDs, Money Market Accts, property, stocks, vehicles, etc.)

|Asset Description |Value |Asset Location / Branch |

| |$ | |

| |$ | |

| |$ | |

I understand the criminal penalties for making false statements and false swearing under O.C.G.A. §16-10-71 and do hereby attest to the truthfulness of the information provided. So sworn and affirmed,

Your signature:___________________________________________________________ SSN:___________________ Date:____/____/_____

Notary Public signature: _____________________________________ Commission expiration date: ____/____/_____

NOTARY SEAL:

COURT ORDERS, SUPPORT ORDERS, AND ARREARAGE OWED

Note: Check each type of order. You MUST provide a certified copy of the order(s) to be enforced.

|[ ] There is NO Court Order requiring either parent to pay support for the children of this case, because: |

|[ ] I am currently married to the NCP (no divorce) |Marriage Date: |Separation Date: |

|[ ] I was never married to the NCP. (You MUST complete a Paternity Affidavit for each child of this NCP) |

|[ ] The mother of the child(ren) was married when the child(ren) was/were |Marriage Date: |Separation Date: |

|born? | | |

|[ ] DIVORCE DECREE [ ] DCSS SUPPORT ORDER [ ] LEGITIMATION ORDER [ ] CUSTODY ORDER |

|Filed in County, State of on [ ] NCP not ordered to pay child support. |

|Support Ordered Amount: $ per [ ] For each child [ ] For All children |

|There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit* |

|[ ] CONTEMPT ORDER [ ] MODIFICATION ORDER [ ] JUVENILE ORDER |

|Filed in County, State of on [ ] NCP not ordered to pay child support. |

|Support Ordered Amount: $ per [ ] For each child [ ] For All children |

|There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit* |

|[ ] URESA / UIFSA ORDER (support order from another state) Note: We must have certified copies |

|Filed in County, State of on [ ] NCP not ordered to pay child support. |

|Support Ordered Amount: $ per [ ] For each child [ ] For All children |

|There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit* |

|[ ] TEMPORARY PROTECTIVE ORDER Note: We must have certified copies |

|Filed in County, State of on [ ] NCP not ordered to pay child support. |

|Support Ordered Amount: $ per [ ] For each child [ ] For All children |

|There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit* |

*Notes: Cases with court orders will require an Affidavit of Arrears to be completed.

Any support NOT paid through Georgia DCSS will require a certified payment history.

|PRIVATE CHILD SUPPORT CASE HISTORY |

|Have you ever had an active child support case with any other state agency, |[ ] Yes If so, list below: |

|private attorney or a private collection agency for the child(ren) listed on | |

|this application? | |

| |Where: |

| |When: |

ARREARAGE AFFIDAVIT: Please show the total amount of support owed and received in each month. Receipts, canceled checks, payment records, etc. may be requested to prove the information in this affidavit.

|Year |Amount |Year |Amount |Year |Amount |

| |Due |Paid | |Due |Paid |

| |Due |

Direct Deposit Authorization Form (For use with online applications only)

To have child support sent directly to your checking or savings account, please read, complete and print this form. Include a voided check or savings account deposit slip with your form. Mail both the voided check or savings account deposit slip and this form to your local Child Support Services office.

| Section 1: AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF CHILD SUPPORT PAYMENTS |

|I authorize the Division of Child Support Services (DCSS) to deposit my child support payments directly into my checking account or savings account as |

|specified below. DCSS is also authorized to adjust any over/under deposit it has made to my checking account or savings account. I understand the |

|deposits/adjustments will be made electronically by ACH transactions and I must allow the Federal Reserve two workdays from the disbursement date to have |

|the funds available to my financial institution. I also understand the following: It is my responsibility to provide correct routing and account |

|information for ACH transmissions by attaching a voided check or financial institution printout to this authorization. DCSS does no pre-note to verify my |

|information. I will immediately notify DCSS if my banking information changes. I must submit a new authorization form to change my direct deposit. I can|

|stop my direct deposit by notifying the DCSS Hotline or local office. I must notify the DCSS local office of any changes to my address. I must include my|

|name and case number on all correspondence regarding direct deposit. The DCSS Hotline and web site provide the date the DCSS system disbursed my payment; |

|I must verify with my financial institution when the payment is posted to my account and funds are available for withdrawal. |

|By signing below I signify that I have read and agree to all of the conditions listed above. |

|Signature:___________________________________________ Date Signed: _______________________ |

|*****PLEASE TYPE OR LEGIBLY PRINT ALL INFORMATION BELOW IN INK***** |

| Section 2: CUSTODIAL PARENT INFORMATION |

|Name: (As it appears on your GA DDS check) |GA DCSS Case Number (if applicable): |

|Social Security Number |Additional GA DCSS Case Numbers: |

|Mailing Address |

|City: |State: |Zip: |

|Day-time Telephone Number: |Email: |

| Section 3: FINANCIAL INSTITUTION INFORMATION |

|Name of financial institution: |

|Routing Number: |Account Number: |Account Type: |

| | |[ ] Checking [ ] Savings |

|City: |State: |Telephone: |

| Section 4: *****FOR DCSS USE ONLY***** |

|Date received: ___/___/___ |Date input: ___/___/___ |Date verified: ___/___/___ |

|Initials: |Initials: |Initials: |

Please verify all information. Then, mail this completed form along with a voided check or savings account deposit slip to the local child Support Services office.

Check here if this is a “Bank-Card Only” account [_]

For your information: If you have access to the internet, you may view your case and obtain payment information on the Customer Online Services website at . First time users are required to register to obtain a user ID and password. Once your case has been registered, you may obtain your IRN by calling the Contact Center at 1-877-423-4746.

[pic]

Georgia EPPICard Debit MasterCard

The Division of Child Support Services (DCSS) no longer mails child support payments in the form of paper checks. If you did not submit a request to have your child support payments deposited into your checking or savings account, a Debit MasterCard will be mailed to you via first class mail within 7 to 10 business days from the date the first child support payment is posted to your case.

The Georgia EPPICard Debit MasterCard allows you to:

1. Make purchases at merchant locations where MasterCard Debit cards are accepted

2. Get cash back at merchant locations where MasterCard Debit cards are accepted

3. Make bank teller and ATM cash withdrawals at locations where MasterCard is accepted

4. Access your child support payments anywhere in the U.S. where MasterCard Debit cards are accepted

[pic]

If you do not receive your EPPICard within 7 to 10 business days from the date your first child support payment is posted to your case, please contact Georgia EPPICard Customer Service at 1-800-656-1347. Once you have received and activated your EPPICard you will be able to receive payment alerts by creating an account on the EPPICard website.

Your Georgia EPPICard will expire every 3 years and a new card will be mailed to you.

Please be sure to update your address with DCSS every time your address changes.

For your information: If you have access to the internet, you may view your case and obtain payment information on the Customer Online Services website at . First time users are required to register to obtain a user ID and password. Once your case has been registered, you may obtain your IRN by calling the Contact Center at 1-877-423-4746.

-----------------------

Georgia Department of Human Services ª% Office of the General Counsel ª% Suite 29.250

ª% Two Peachtree Street, NW ª% Atlanta, Georgia 30303-3142 ª% 404-657-9761 ª% 404-657-1123 (Fax)

Nathan Deal, Governor Services ▪ Office of the General Counsel ▪ Suite 29.250

▪ Two Peachtree Street, NW ▪ Atlanta, Georgia 30303-3142 ▪ 404-657-9761 ▪ 404-657-1123 (Fax)

Nathan Deal, Governor Keith Horton, Commissioner

Download Doc File