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Child Support Agreement 06

This document is a Parent Responsibility Agreement form used to document informal child support arrangements between custodial and non-custodial parents receiving child care assistance. The form requires information about the custodial parent, non-custodial parent, children, and details of monthly support provided. Signatures from both parents are also required, along with receipts for cash or in-kind support payments for the previous 6 months to verify the arrangement at recertification. Failure to complete and submit this form or provide receipts will result in termination of child care assistance services.

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Nicole Nikka Mike Clarence
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248 views1 page

Child Support Agreement 06

This document is a Parent Responsibility Agreement form used to document informal child support arrangements between custodial and non-custodial parents receiving child care assistance. The form requires information about the custodial parent, non-custodial parent, children, and details of monthly support provided. Signatures from both parents are also required, along with receipts for cash or in-kind support payments for the previous 6 months to verify the arrangement at recertification. Failure to complete and submit this form or provide receipts will result in termination of child care assistance services.

Uploaded by

Nicole Nikka Mike Clarence
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Atencion:

2415 South Austin Ave, Ste. 105


Para obtener esta u otras formas on Espanol,
Denison, TX 75020
favor the llamar a esta oficina al
(903)463-9997/ (888)813-1992
903-463-3073 fax (903)463-9997 / (888)813-1992
childcare@workforcesolutionstexoma.com

Parent Responsibility Agreement


Informal Child Support Form
State law requires that any family receiving child care assistance comply with the Parent Responsibility Act. This Act includes receiving child
support for each individual child in the household. Failure to comply with this requirement will result in termination of services.

When to use this form: This form is to be used ONLY in the event there is an informal child support arrangement between the custodial and non-
custodial parent(s), not filed with the Attorney General’s office or private child support agency.

Who completes this form: This form is to be completed by the parent NOT living in the household, the non-custodial parent.

IMPORTANT: if the children in the household have informal arrangements with different non-custodial parents, a separate form must be
completed with each non-custodial parent.

Please make copies of this form for each child’s non-custodial parent to complete and sign. Child care assistance will be terminated or denied if
we do not receive this documentation on each child.

Type of support received: In Kind Support In Lieu Support


In Kind Support: the non-custodial In Lieu Support: the non-custodial
parent is paying for groceries, parent is giving you cash support
diapers, formula or other payments
miscellaneous items

Name of custodial parent:

Name of non-custodial parent:

Non-custodial parent address:

Non-custodial parent telephone:

I, the non-custodial parent, hereby attest that the children listed below are my children and I provide for them through a
monetary or in-kind support method (Please include a monetary amount for in-kind items such as diapers, formula, rent, etc.).
Child Name (First and Last Name) Total Monthly Support ($) Date Child Support Started

Note: At every recertification you will need to supply 6 months of receipts and attach to this form for cash payments or in-kind
support such as diapers, formula, rent, etc; failure to supply receipts will result in a $25 sanction added to your parent fee.

SIGNATURES

Custodial Parent Signature Date

Non-Custodial Parent’s Signature Date

Workforce Solutions Texoma is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Individuals with speech and/or
hearing impairments may call 711 for assistance.
Form 2080-revised 8.08;6/11

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