ISETS NUMBER:

7996652

Date: 08/16/2024

Name: KEYONA TINKER

Address:

CP INVL PKT

You recently contacted our office about opening a child support case with the Marion County Prosecutor’s
Office, Child Support Division. You will need to complete the enclosed packet to open a case. Once
completed, return the packet, coversheet AND all required documents. You can mail them into the office
at the address listed above, fax them to 317 327-1801 or email them to CSDNewApplication@indy.gov in
PDF Format. We will not accept pictures/images (JPG), WORD DOC, links, ZIP Files. PNG Files, sign-ons or
download attachments through email of the documents. You will send in the items ATTENTION: INTAKE. DO
NOT send in originals. The documents you provide will be scanned and shredded. Any documents
provided will not be returned.

If you do not return the packet, we will not be able to process your request. If you fail to send ALL of the
required documents, you will receive a letter detailing the missing and/or incomplete items. If the missing
and/or incomplete items are not provided in response to that letter by the date given, your request will not
be processed and your packet may be destroyed. Please note that if your packet is destroyed and you
decide you still wish to proceed with your request, you will be required to complete a new packet. Please
understand this is the first step to open a case through our office. You will be contacted for an
appointment once all information is completed and received to finish the process. Court dates will be
set at a later if necessary.

TANF RECIPIENTS: If you are receiving TANF benefits, cooperation in establishing paternity, medical
support and child support is required. If you fail to fully cooperate in completing this process, your
caseworker will be notified and your TANF benefits may be sanctioned and your Title IV-D case will not be
processed and may be closed. You have 21 days to complete and return the packet along with the
required items.

If you fail to respond to our office or if you do not respond within the required time-frame, we may
initiate closure of your case if appropriate

If you have any questions or concerns, please contact our office at 317 327-1800.

Sincerely,
Child Support Division

Page 1 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652

ITEMS REQUIRED
Please read thoroughly

IN ORDER TO EFFECTIVELY AND EFFICIENTLY PROCESS YOUR REQUEST, THE FOLLOWING ITEMS MUST BE
RETURNED WITH THE COMPLETED PACKET. IF YOU ARE MISSING ANY OF THESE ITEMS, WE WILL NOT BE ABLE TO
ASSIST YOU
A.ITEMS REQUIRED FOR EVERY CASE

1. Valid Photo ID. Your request will not be processed without a valid Photo ID per IRS regulations.
2. Death certificate or obituary. If applicable.
3. Verified Support Statement. You must provide proof of any payments for the benefit of the
child(ren) made outside the Clerk’s Office or INSCCU to be considered for credit.
4. Protective Order/No Contact Order. If applicable.
5. Proof of Medical Insurance for the Child(ren). This includes a copy of the insurance card
showing the Policy Number, Group Number, the coverage type and the name, address and phone
number of the insurance carrier. If you do not have insurance coverage for the child please
indicate same.
6. Other Party information. You must provide a current address, place of employment, social
security number, date of birth, and photograph of the other party if you have that information.
B. ITEMS REQUIRED TO OPEN A NEW CASE OR REOPEN A CASE
1. Child(ren)’s Birth Certificate.
2. Paternity Affidavit. If applicable.
3. Marriage Certificate or Marriage License. If applicable.
4. All Court Orders Issued on the Case. Examples: protective order, no contact order, divorce
decree, preliminary order, paternity judgment, modification and letters of guardianship.

C.ITEMS REQUIRED TO ESTABLISH OR MODIFY AN ORDER

1. Proof of Income. If you are working or have worked in the last 90 days, provide your three (3)
most recent pay stubs. If you just started a new job, provide an award letter from the employer
stating how much you will make an hour and how many hours per week you will work. If you
receive Social Security benefits, provide your award letter for the current year. In addition, you
must provide your Federal and State tax returns, AND all W2s from previous year.
2. Proof of work-related childcare expenses. If applicable. Proof must be in the form of a
statement from the provider detailing the amount paid each week for the childcare.
3. Proof of Child(ren)’s Social Security Benefits. If applicable. This includes derivative benefits
the child(ren) receive and/or benefits received individually. Proof must be in the form of the
current year award letter for each child(ren). If derivative benefits are received, provide
documentation showing the amount received in each year and any lump sum received by each
child(ren).

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ISETS NUMBER:
7996652

If inaccurate or false information is provided your modification request may be denied.

IF RECEIVING TANF:
As a condition of receiving TANF benefits, cooperation in establishing paternity, medical support and child
support is required. If you fail to fully cooperate in completing this process, your caseworker will be notified
and your TANF benefits may be sanctioned and your Title IV-D case will not be processed and may be
closed.

Sincerely,

Child Support Division

Page 3 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652

CHILD SUPPORT

INTERVIEW COVERSHEET
(MUST BE RETURNED WITH COMPLETED PACKET)

ATTENTION: INTAKE

DATE: _______________________________

YOUR NAME: ________________________________________________________________________

CONTACT NUMBER: _________________________________________________________________

OTHER PARTY’S NAME: ______________________________________________________________

DOES SHE/HE HAVE A COURT ORDER TO PAY SUPPORT FOR THE CHILD(REN) ON THIS
CASE? _____________________________________

ARE YOU ORDERED TO PAY CHILD SUPPORT FOR THE CHILD(REN) ON THIS ……
CASE? _____________________________________

FULL NAME AND DATE OF BIRTH OF CHILD(REN) ON THIS CASE:

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

WHAT IS YOUR REASON FOR REQUESTING THIS INTERVIEW?

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Page 4 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
How to Fill out the Enrollment Packet:
This information sheet is to assist parties with the most commonly asked questions we receive in our office on how
to fill out the Enrollment Packets.
**Please note: Your packet may not have every page listed below. If you do not see the page listed below in your
packet, you do not need to fill it out at this time.**
1. CHILD SUPPORT INTERVIEW COVERSHEET: Fill out entirely
2. How to fill out YOUR INFORMATION: Fill out entirely.
• To fill out the DATE LAST WORKED line, provide the Month and Year of the date you last worked. If
you have never worked, indicate NEVER WORKED on the line.
3. How to fill out OTHER PARTY INFORMATION: Fill out entirely.
• If you do not know an address for the Other Party, you must write the City and State of where you believe
the other party resides. If the party lives out of state and you do not know what city, but you can provide
the state, write in UNKNOWN for City, and then provide the STATE.
• For Race, Height, Weight, Hair Color, and Eye Color, you must provide information on this line. Use the
description of the other party from the last time you saw them.
• Provide other party Date of Birth(or approximate age if DOB is unknown)
4. How to fill out CHILD(REN) INFORMATION: Fill out entirely for each child.
• We must have all information requested including the County and State the child was conceived in.
• You must also list Medical Insurance information for the children on the case. This information is
requested at the bottom of the page.
5. How to fill out CUSTODIAL PARENT (CP) INSTRUCTIONS FOR SUPPORT RECEIVED FROM NON-
CUSTODIAL PARENT (NCP):
• For Question A: list Date of Birth for Oldest Child on this case. For Question B: List the Date of original
court order or last court setting of arrears. If not applicable, indicate N/A. For questions C-Q: Indicate
Yes or No and provide additional information if requested on the line.
6. How to fill out IN-DEPTH INTERVIEW: Fill this page out entirely.
• For questions 6 & 7: provide approximate information if you do not know the exact.
• For question 8 & 9: You must answer these questions and cannot leave them blank. If you listed Yes for
question 8 and provided Name(s), you MUST fill out questions 12-14B.
7. How to fill out VERIFIED SUPPORT STATEMENT:
• If you are the Custodial Parent: Put down how much $ the other party has given you for child support
outside of the Clerk’s Office since order was put in place (if none put $0). Also list the COURT
ORDERED CHILD SUPPORT date on the 2nd line. #2-3 if they don’t apply since the order put n/a on all
lines. If they do apply since the date of the order put the year and month for each one. #4 if child receives
social security complete that information and if not put n/a on all lines. PLEASE DON’T FORGET THE
HEADING—LIST YOURSELF AS PETITIONER AND OTHER PARTY AS RESPONDENT.
• If you are the Non-Custodial Parent: #1 Put down how much $ you have given the other party for child
support outside of the Clerk’s Office since order was put in place(if none put $0). Also list the COURT
ORDERED CHILD SUPPORT date on the 2nd line. #2-3 if they don’t apply since the order put n/a on all
lines. If they do apply since the date of the order put the year and month for each one. #4 if child receives
social security complete that information and if not put n/a on all lines. PLEASE DON’T FORGET THE
HEADING—LIST YOURSELF AS PETITIONER AND OTHER PARTY AS RESPONDENT.
8. How to fill out CUSTODIAL PARENT FINANCIAL DECLARATION CHECKLIST: Fill out the pages entirely.
• On the last Question it asked about visitation with the non-custodial parent; You must enter an annual
actual number of overnights on this line. (This information is needed in court to complete the Child
Support Worksheet)
If you have questions on how to fill out this Packet that is not listed above, please call our office at 317-327-1800 for
assistance.

Page 5 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
YOUR INFORMATION (12-19-19)
Date: _________________________ (Please circle) Male Female
Full Legal Name: _______________________________________________________________________________
Last First Middle Maiden

Home Address: __________________________________________________________________________

Street City State Apt Zip

Home Phone: (____)__________________________ Cell/Other Phone:(_____)______________________

Email address: _________________________________________________________________________________
Social Security Number: ______________________ Date of Birth: _______________ Race: _________________
County, City, and State of Birth: ___________________________________________________________________
Employer Name: ________________________________________________________________________
Employer Address: ______________________________________________________________________________
Employer Phone Number: (_______)_________________________________Date Last Worked______________
What state assistance do you currently receive?
What state assistance do you currently receive?
TANF Medicaid Food Stamps None
What state assistance have you received in the past?
TANF Medicaid Food Stamps None
Do the child(ren) receive monthly social security benefits? Y N

Have you ever been married? Y N

Name of Spouse: ___________________________ Name of Spouse: ___________________________
Marriage Date: ____________________________ Marriage Date: _____________________________
City and State: ____________________________ City and State: _____________________________
Divorce Date: __________________________ Divorce Date: __________________________
Separation Date: _______________________ Separation Date: ________________________
Do you have a protective order/no contact order against Father/Mother? Y N
If yes, who does the order cover? ___________________________________________________________
Date protective order/NCO in effect: _________________
Date protective order/NCO expires: __________________
Are you currently represented by an attorney? Y N
Have you or the father filed a case in the past for this child(ren) in the past? Y N
If so, where___________________________________________________________________(City, State)
Did the non-custodial parent sign a Paternity Affidavit? Y N Where ____________________
Is the non-custodial parent court ordered to pay child support? Y N
Date of the court order? ___________________ County & State of court order: _____________________
When is the last payment you received? ____________________________________________________
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ISETS NUMBER:
7996652
OTHER PARTY INFORMATION
Full Legal Name: _____________________________________________________________________________
Last First Middle Maiden

Alias: ____________________________________________________ (Please circle) Male Female

Current Physical Home Address:
____________________________________________________________________________________________
Street City State Apt Zip

Information Received From: ___________________________ Resides with: ____________________________

_____________________________________________________________________________________________
Prior addresses: ______________________________________________________________________________
_____________________________________________________________________________________________
Home Telephone Number: (____)_________________ Cell/Other Phone Number: (_____)_________________
Social Security Number: _________________________________________
Date of Birth: ___________________ Approximate age if is D.O.B. unknown: ____________________________
County, City, and State of Birth: ___________________________________________________________________
Race: __________ Height: ________ Weight: ________ Hair Color: ____________ Eye Color: ____________
List any distinguishing or identifying features: ________________________________________________________
Other Parent’s Employer’s Name: _________________________________________________________________
Other Parent’s Employer’s Address: ________________________________________________________________
Employer Telephone Number: _____________________________________________________
Other parent’s mother’s name: _______________________ Other parent’s father’s name: ____________________
Other parent’s known relatives/spouse/girlfriend/boyfriend (name and relationship):
______________________________________________________________________________________________
______________________________________________________________________________________________
Has he/she ever served in the military? Y N Branch of service: ____________________________________
Has he/she ever been incarcerated? Y N Facility: ____________________________________________
Has he/she ever resided in other states? Y N States: _____________________________________________
Other parent email address________________________________________________________________________
Other parent social media information_______________________________________________________________
______________________________________________________________________________________________
Is the Other parent receiving SSD or SSI? Y N Type: _____________________
Does the Other parent have other child(ren) than the one you are here on? Y N
Are they Ordered to Pay Support? Y N
Names of dependents who reside with him/her:
______________________________________________________________________________________________
______________________________________________________________________________________________

Page 7 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
CHILD(REN) INFORMATION
1. Full Legal Name: _______________________________________________________________ Male Female
Last First Middle
Date of Birth: _____________________ Social Security Number________________________________
Date, county, city, and state of conception:___________________________________________________________
County, City, and State of Birth: ___________________________________________________________________
Hospital of Birth: _______________________________________________________________________________

2. Full Legal Name: _______________________________________________________________ Male Female

Last First Middle
Date of Birth: _____________________ Social Security Number________________________________
Date, county, city, and state of conception:___________________________________________________________
County, City, and State of Birth: ___________________________________________________________________
Hospital of Birth: _______________________________________________________________________________

3. Full Legal Name: _______________________________________________________________ Male Female

Last First Middle
Date of Birth: _____________________ Social Security Number________________________________
Date, county, city, and state of conception:___________________________________________________________
County, City, and State of Birth: ___________________________________________________________________
Hospital of Birth: _______________________________________________________________________________

4. Full Legal Name: _______________________________________________________________ Male Female

Last First Middle
Date of Birth: _____________________ Social Security Number________________________________
Date, county, city, and state of conception:___________________________________________________________
County, City, and State of Birth: ___________________________________________________________________
Hospital of Birth: _______________________________________________________________________________
**********************************************************************************************
Is medical insurance available? Yes ______ No ______
If no, why not__________________________________________________________________________________
Child(ren) covered by medical insurance? Yes ______ No ______ Medicaid ______
If YES, who provides the insurance? Mother ______ Father ______ Other _______________________
Have you provided coverage information to the other parent? Yes ______ No ______
Policy # __________________ Group # ________________ Group Name _____________________________
Coverage Type: Medical ______ Dental ______ Vision ______ Hospital ______ Prescription _____
Insurance Carrier Name: ___________________________________________ Phone #:___________________
Address: ______________________________________________________________________________________
(Note to employee: Please include information in ISETS, on note sheet, and in the file regarding medical insurance)

Page 8 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
Custodial Parent (CP) Instructions for Support Received from Non-Custodial Parent
(NCP)
1. You may need to sign a Verified Statement for any support you received from the non-custodial parent for
the benefit of the minor child(ren) in this case. We will need the amount of support received since the
original child support order was entered or the last time the child support arrears were set in court, whichever
is later. If this case is a new paternity, please answer the questions below using the child’s date of birth as
the starting point for any support paid. If you are the putative father please request a different form from the
front desk.

2. This statement will be used to update your child support account.

3. The statement will be signed under the penalties of perjury.

4. Please review the list below for any money you might have received. The items below do not represent
everyway a non-custodial parent could provide support. The list is a guide as to how a the non-custodial
parent (NCP) may have provided support for the minor child(ren) in this case outside the Clerks’ Office or
the Indiana State Central Collection Unit (INSCCU) .

If you answer yes to a question please list the amount of support provided (If the payment was sent by the
Clerk’s Office or the Indiana State Central Collection Unit (INSCCU) those payments should not be included
below):

a. Oldest child’s date of birth for this case (if no court order)____________

b. Date of original court order or last court setting of arrears (if applicable)
____________

c. Has NCP paid cash or checks directly to you since the date of original order, court
setting arrears date or child’s date of birth? ___________

d. Has the NCP made any direct deposits into your savings or checking account since
date listed? ________________

e. Has NCP made any direct deposits into your child’s savings or checking accounts
since date listed? ______________

f. Have you received any money from NCP’s military allotment or NCP’s veterans
benefits since date listed? ______________

g. Has the child received a lump sum from the Social Security Administration based on
NCP’s disability since date listed? _______________

h. Does the child receive a monthly disability check from Social Security because the
NCP is disabled? ____________
How much per month: ___________
When did the child start receiving the monthly benefit? __________

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ISETS NUMBER:
7996652

i. Has the NCP paid for any of your bills or the child’s bills by agreement instead of
paying the child support through the court? ______________

j. Has the child ever lived with the non-custodial parent since date listed?
_______________
If yes, when? __________________

k. Have you and the NCP lived together since date listed? ______________

l. Has the NCP helped pay the household expenses and the child’s expenses since date
listed? If yes, when? ________________

m. Has the NCP provided items in your home for the benefit of the child since date
listed? ________________

n. Has the NCP paid your utilities, insurance, cell phone bill or rent since date listed?
________________

o. Has the NCP put any money on any type of credit card for the benefit of the child
since date listed? ___________________

p. Are the numbers you are giving an exact figure or an estimate? ______________

q. Have you received any other support from the other parent?
1. How received: _____________________________
2. How much (if applicable)_____________________

If you are giving the NCP credit and the above does not apply, please explain why below.
______________________________________________________________________________________________
______________________________________________________________________________

________________ ______________________________
Date Custodial Parent

Original: 3-4-11
Revised: 3-8-11, 3-10-11, 3-28-11, 4-27-17, 8-28-19

Page 10 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
ISET NUMBER: Title IV-D

TITLE IV-D NOTICE AND WAIVER

I, the undersigned person requesting child support enforcement services, hereby acknowledge that the Prosecuting
Attorney is an agent of the State of Indiana and the Indiana Family and Social Services Administration, and cannot
and does not serve as a private attorney to custodial parents or other persons. The function of the Office of the
Prosecuting Attorney is to protect and promote the interests of the State at large and the best interests of children in
particular, and these interests may conflict at times with my interests or desires.

I understand that the Prosecuting Attorney does not actually represent custodial parents or custodians, but is merely
providing child support services under Title IV-D of the federal Social Security Act. These services are limited to:
(1) location of absent parents: (2) establishment of paternity and other support orders; (3) enforcement of support
orders; and (4) modification of support orders. Furthermore, I realize that the Prosecuting Attorney is not my
personal attorney, and that I may need to consult with a private attorney or a legal services agency regarding my legal
rights, including but not limited to dissolution, separation, paternity, custody, visitation, property settlement,
judgments, or educational support.

I acknowledge that I am not entering into an attorney-client relationship with an attorney in the Office of the
Prosecuting Attorney, and that any information provided to the prosecutor's Office Child Support Division or its
agents is not information protected by an attorney-client privilege. Any information provided to the office of the
Prosecuting Attorney may be used by that office in the prosecution of the information. Any information provided
may be used and referred to local, state or federal law enforcement and to the Indiana Department of Child Services
for prosecution of any possible violations or crimes. I further acknowledge that involvement in the Title IV-D child
support program does not protect me from prosecution for any criminal offense or civil violation. I further
acknowledge that if a case is filed that the information filed will not necessarily by confidential.

NOTE: THIS FORM IS A WAIVER OF LEGAL RIGHTS AND SHOULD BE SIGNED ONLY AFTER BEING
READ CAREFULLY. YOUR SIGNATURE VERIFIES THAT YOU HAVE READ AND UNDERSTOOD THE
TERMS OF THIS DOCUMENT.

I have read the above and fully understand the contents of this waiver and consent to its terms. I affirm under the
penalties of perjury that the foregoing representations are true.

Date: ________________________ _______________________________

Signature of Parent

Witness_______________________

Page 11 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652

FOR YOUR RECORDS

Enforcement that Occurs on Open Title IV-D Cases When there is an Order

Income Withholding
The term “income withholding” refers to a process in which child support payments are withheld from the paycheck
of the noncustodial parent. Income withholding is required in all child support orders, unless a court finds that
exceptional circumstances dictate otherwise. In addition to court ordered income withholding, the Prosecutor’s Office
has administrative authority to issue income withholding orders when the noncustodial parent falls at least one month
behind in support payments. If an obligor subject to an income withholding order becomes delinquent in his or her
obligation, unless otherwise ordered by a court, the Prosecutor’s Office may increase the weekly amount withheld
towards the arrearage.

Circumstances in which the Prosecutor’s Office would not send an income withholding to the employer:
· Noncustodial parent is paid by cash
· The noncustodial parent receives SSI
· The noncustodial parent is a contractor or sub-contractor
· The noncustodial parent is self-employed
· The noncustodial parent was never ordered by the court to pay by income withholding

Caps on allowable garnishment:

Federal and state laws provide a maximum amount of an individual’s disposable earnings for any workweek that may
be subject to garnishment. The laws take into account whether the individual is supporting another spouse or
dependent child.

Judicial Enforcement
of Court Orders
If administrative enforcement remedies are not sufficient in enforcing the child support obligation, the Marion
County Prosecutor’s Office may file a civil contempt action to enforce the order. A contempt proceeding is a civil
remedy designed to coerce an individual to pay court-ordered support. If the Court finds that a child support obligor
has willfully failed to pay support, the Court may find the parent in contempt and order the parent held in jail until
the contempt is “purged” by the paying of a purge bond in an amount ordered by the Court. Once the bond has been
paid, the entire bond is applied toward the child support. The Court may also order the noncustodial parent’s property
seized and sold to pay all or some of the obligor’s child support arrearage. The purpose of Court sanctions for
contempt is to coerce payment of child support, not to punish.

Tax Refund Interceptions

The Prosecutor’s Office has administrative authority to intercept the tax refunds of noncustodial parents who owe a
child support arrearage, and to apply the intercepted amount towards the arrearage. In order to qualify, a
noncustodial parent must be at least $500.00 behind in court ordered support in non-welfare cases, or $150.00 in
welfare cases. Tax refund interceptions are available for state and federal returns. The Prosecutor’s Office cannot
disclose the status of the interception to custodial parents.

Liens
Under Indiana Law, any child support that is past due and unpaid constitutes a lien against the noncustodial parent’s
property for the amount of the arrearage. This means that the noncustodial parent may not sell the property
(example: a car) without first satisfying the child support arrearage.

This also means that the property may be seized and sold to satisfy the child support arrearage.

Page 12 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
Driver’s License Suspension
When an obligor has a child support arrearage of at least $2,000.00 OR the equivalent of
12 weeks’ worth of support, the obligor’s driver’s and recreational license become eligible for suspension. A warning
letter will be sent to the obligor. If no arrangements are made or the obligor does not start paying the full court-
ordered amount, the next step is a letter to advise the BMV or the professional licensing agency to suspend the
license. Once a driver’s or professional license is administratively suspended, reinstatement is possible only by
contacting the Prosecutor’s Office and following through on an established payment plan. Once the payment plan has
been established, it will take approximately 14 days for a reinstatement to be completely processed by the BMV or
professional licensing agency.

Passport Suspension
Once a noncustodial parent’s child support arrearage reaches at least $2,500.00. the parent’s passport becomes
eligible for suspension, revocation or restriction. Passport suspension is a cooperative process between the
Prosecutor’s Office, the U.S. Department of Health and Human Services and the U.S. Secretary of State.
Reinstatement requires compliance with a payment plan established by the IV-D agency.

Lottery Interception
When a non-custodial parent owing a child support arrearage wins a lottery prize of at least $600.00, the Indiana
Lottery Commission is required to withhold the winnings and apply it to the arrearage. Child support arrearages are
satisfied before other debts, such as judgments and some tax liens. Lottery proceeds are applied first to any existing
state debts, and then to any child support owed.

Credit Bureau Reporting

The Prosecutor’s Office reports non-custodial parents who owe $1,000 or more in arrearages to a credit reporting
service.

Criminal Charges for Nonpayment

In Indiana, a person who knowingly or intentionally fails to provide support to the person's dependent child commits
nonsupport of a child, a Level 6 felony, punishable by incarceration up to 2 and 1/2 years. The offense is a Level 5
felony if the individual has a prior conviction for criminal nonsupport, and is punishable by incarceration up to 6
years. Different penalties may apply for nonsupport prior to July 1, 2014. All charging decisions are at the discretion
of the Prosecutor’s Office.

Federal law also makes nonsupport a crime where the child and noncustodial parent reside in different states and the
arrearage is at least $5,000.00. Federal criminal nonsupport cases are referred by the local prosecutor to the U.S.
Attorney’s Office. From there, the U.S. Attorney’s Office reviews the available information and decides whether to
pursue the matter. If the case warrants prosecution, the U.S. Attorney’s Office will conduct an investigation, locate
the absent parent, and file the action in federal court. The process may take several months or longer to complete.

Page 13 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652

INDIANA CHILD SUPPORT SERVICES ENROLLMENT FORM

INSTRUCTIONS:
1. Complete this form by providing the requested information
2. Take or mail the signed form to your County Child Support Office
NOTICE TO ENROLLEE
All custodial parents and Non-Custodial Parents may enroll to receive child support services. There is no enrollment fee or residency
requirement. Child support services include:
Parent Location
Establishment of Paternity
Establishment, modification, and/or enforcement of child support obligations and
Establishment, modification, and/or enforcement of medical support for dependent children
Information provided for this enrollment is confidential and protected to prevent unauthorized disclosure
ENROLLEE INFORMATION
Last Name First Name Middle Name Suffix (jr., III, etc…)

Other Names Used Relationship to dependent Do you have primary physical custody of the dependent(s)
(mother, father, guardian, other) on this form? _____Yes ______No

Date Of Birth (month, day, year) Gender Race Social Security Number/ITN

Home Address (Full Address including number and street, rural route number, apt or room number, city , state, and zip code)

Mailing Address, if different from above (Full Address including number and street, rural route number, apt or room number, city ,
state, and zip code

Telephone Number (cellular) Telephone Number (home) Telephone Number (work) Email Address

Do you need special assistance? Special assistance needed here (i.e. physical, hearing impaired, language
____Yes _____No (If Yes, complete next box) interpreter, other)
Do you believe in pursuing child support services may result in physical or emotional harm to your or your children?
_______Yes ________No If yes, paralegal may discuss additional protections offered when providing child support services.
Do either of the following apply? Are you currently employed? Name of employer
Active military Duty_____ _____Yes ______No If yes, complete next two
Currently incarcerated______ boxes
Address of employer (Full Address including number and street, rural route number, apt or room number, city , state, and zip code)

Marital status of enrollee to other parent

____Never Married _____Divorced _____ Divorce Pending _______ Married ______Legally Separated
______Separated
Do you have a private attorney handling paternity and/or support Name of Attorney (full name)
matters for dependents listed in this form? _____Yes ______No (If
yes, complete next box)
Are you applying for services for an unborn child? Due Date (month, date, year)
_____Yes _____No (If yes, complete next box)
DEPENDENT #1 INFORMATION
Last Name First Name Middle Name Suffix (jr., III, etc…)

Date Of Birth (month, day, Gender Race Social Security Number/ITN

year)

Has paternity been established for this child? How was paternity established? Where was paternity established? (County and
_____Yes _____No _____Unknown State)

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ISETS NUMBER:
7996652
(If yes, complete next two boxes) ____Court order _____Paternity
affidavit
(If court order, complete next box)
Is there a child support obligation for this Where was support ordered? (County and State) Enrolled in
dependent? ___Yes ___No ___Unknown Medicaid?
(if yes, complete next box) ____Yes ___No
DEPENDENT #2 INFORMATION
Last Name First Name Middle Name Suffix (jr., III, etc…)

Date Of Birth (month, day, Gender Race Social Security Number/ITN

year)

Has paternity been established for this child? How was paternity established? Where was paternity established? (County and
_____Yes _____No _____Unknown ____Court order _____Paternity State)
(If yes, complete next two boxes) affidavit
(If court order, complete next box)
Is there a child support obligation for this Where was support ordered? (County and State) Enrolled in
dependent? ___Yes ___No ___Unknown Medicaid?
(if yes, complete next box) ____Yes ___No
DEPENDENT #3 INFORMATION
Attach separate page with information requested below for all additional dependents on the case
Last Name First Name Middle Name Suffix (jr., III, etc…)

Date Of Birth (month, day, Gender Race Social Security Number/ITN

year)

Has paternity been established for this child? How was paternity established? Where was paternity established? (County and
_____Yes _____No _____Unknown ____Court order _____Paternity State)
(If yes, complete next two boxes) affidavit
(If court order, complete next
box)
Is there a child support obligation for this Where was support ordered? (County and State) Enrolled in
dependent? ___Yes ___No ___Unknown Medicaid?
(if yes, complete next box) ____Yes ___No
Other Parent Information
Attach separate page for information listed below for other potential parents of the child(ren) listed if paternity has not been
established
Last Name First Name Middle Name Suffix (jr, III, etc…)

Other Names Used Relationship to dependent (mother, father, guardian, Does this parent have primary physical
other) custody of the dependent(s) on this form?
_____Yes ______No
Date Of Birth (month, day, year) Gender Race Social Security Number/ITN

Height Weight Hair Color Other distinguishing characteristics (eye color, tattoos)

Home Address (Full Address including number and street, rural route number, apt or room number, city , state, and zip code)

Mailing Address, if different from above (Full Address including number and street, rural route number, apt or room number, city ,
state, and zip code

Telephone Number Telephone Number Telephone Number (work Email Address

(cellular) (home)

Does this parent need special assistance? Special assistance needed here (i.e. physical, hearing impaired, language interpreter,
____Yes _____No (If Yes, complete next other)
box)

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ISETS NUMBER:
7996652
Do either of the following apply? Current or Last Known Employer Employer telephone
____Active military Duty ____Currently number
incarcerated
Address of employer (Full Address including number and street, rural route number, apt or room number, city , state, and zip code)

Does this parent have a private attorney handling paternity and/or Name of Attorney (full name)
support matters for dependents listed in this form? _____Yes
______No
(If yes, complete next box)
AFFIRMATION AND AGREEMENT
• I hereby swear and affirm under the penalties of perjury that the information contained in this form is true and correct to
the best of my knowledge. Providing false information could result in perjury charges being filed against me.
• I understand that child support services DO NOT include establishment or enforcement of parent time and parenting time
credits, the assignment of the right to claim a child as a dependent for federal or state tax purposes, nor any matters
other than those associated with establishment of paternity (if needed) and the financial support of dependent children.
• I am advised that attorneys and staff at the Child Support Bureau and County Child Support Office providing these child
support services represent the State of Indiana and do not represent the enrollee or any other person or entity.
Communications between the enrollee or any other participants and the Child Support Bureau or County Child Support
Office are not confidential communications protected by the attorney/client privilege under IC 34-46-3-1.
• I understand that I must cooperate with the County Child Support Office in order for my case to be processed, and non-
cooperation can result in termination of child support services. I further understand that this enrollment to receive child
support services does not guarantee successful action on the case but rather all reasonable attempts will be made to
obtain successful results.
• I understand that I may terminate services by notifying the County Child Support Office handling my case in writing that
services are no longer desired. Services may only be terminated in accordance with 45 C.F.R. 303.11. Termination of
these services does not modify or terminate existing child support orders or obligations.
• I authorize the Indiana State Central Collection Unit (INSCCU) to endorse and negotiate any checks received by INSCUU for
payment of support on my child support case.
Printed name of parent/guardian (if enrollee is an unemancipated Signature of parent/guardian (if enrollee is an unemancipated
minor) minor)

Printed name of enrollee I agree that if I am overpaid, the state may recoup the amount of
the overpayment from future child support payments owed to me
___Yes ___No
Signature of enrollee Date signed (month, day, year)

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ISETS NUMBER:
7996652
AFFIDAVIT

I, __________________, hereby state as follows:

1. I hereby request that the Marion County Prosecutor’s Office assist me in filing a paternity action
against ____________ to establish paternity and/or support of the child,_________________.

2. I understand that if paternity has been previously established by execution of a paternity affidavit
or court order, genetic testing is not ordinarily available.

3. I understand that where paternity has not been established by affidavit or court order, DNA testing
may be ordered in this case. This would require me, the child, and any other alleged father(s) to
be tested. I acknowledge that by refusing this test, the court may issue appropriate orders,
including, but not limited to, establishing paternity or dismissing the case.

4. I acknowledge and agree that, unless I am an active TANF recipient at the time a DNA test is
ordered, I may be required to pay for all or part of the genetic testing cost.

5. I acknowledge and agree that the information I provided on the Title IV-D Application, Title IV-
D Waiver, Application Interview Cover Sheet, Custodial Parent (CP) Instructions for Support
Received from Non-Custodial Parent (NCP) Form, In-depth Interview, and Scope of Paternity
Services Provided are true and accurate to the best of my knowledge.

6. I acknowledge and agree that if the State of Indiana or its agents pays the initial cost of DNA
testing, I may be ordered to reimburse the State for such costs, especially if the man alleged to be
the child’s biological father is excluded by DNA testing.

7. I understand that if I do not fulfill this agreement, the Marion County Prosecutor’s Office may
file a court petition to dismiss the paternity action.

VERIFICATION

I AFFIRM, UNDER THE PENALTIES FOR PERJURY, THAT THE INFORMATION GIVEN IS TRUE
AND ACCURATE TO THE BEST OF MY KNOWLEDGE

______________________________ ___________________
Petitioner Date

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ISETS NUMBER:
7996652

IN-DEPTH INTERVIEW

1.Alleged Father's Name:

2. Mother's Name:
3.Child's Name:
4.Child's DOB:

5.Have you ever been married? _________

5B. If yes, name of all spouses, date married, date marriage ended:

6. When and where did you become pregnant with this child? _______ Month _____ Year _____ State
7. When was your last regular menstrual period before you became pregnant?
_______ Month _____ Year
8. In the month you became pregnant, the month before and the month after, did you have sexual
intercourse with anyone other than _________? ________________
9. If so, list names(s) ________________________________________________________
10. Was the child born prematurely or past the due date? _________
11. How much early or late was the child born? _______________________________________
12. How often did you have intercourse with ________ in the month before you became pregnant?
______________________
12B. Same question for any other man ________________________________________

13. How often did you have intercourse with __________ in the month you became pregnant?
__________________________
13B. Same question for any other man________________________________________

14. How often did you have intercourse with ________________ in the month after you became pregnant?
____________________________
14B. Same question for any other man ________________________________________

15. Have you filed a paternity case for this child anywhere in the past? ________
15A. If so, list the details
_____________________________________________________________________________________

I AFFIRM, UNDER THE PENALTIES FOR PERJURY, THAT THE INFORMATION GIVEN IS TRUE
AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

___________________________ Dated:____________________
Petitioner

Page 18 of 19 (CP INVL PKT)

ISETS NUMBER:
7996652
Scope of Paternity Establishment Services Provided

1. I acknowledge that I have named all possible (alleged) fathers for each child in this case.

2. I understand that if all possible (alleged) fathers named at this time are excluded as a biological
father to the child(ren) on this case, this case will be closed.

3. I understand that if this case is closed due to exclusion of all potential fathers I have named today,
the Marion County Prosecutor’s Office will not open or pursue another possible (alleged) father for
the child(ren) listed on this case. At the discretion of the Prosecutor’s Office, however, the case may
be re-opened if I provide positive genetic test results from an accredited laboratory that I have
obtained myself, regardless of the type of case.

4. I understand that if all possible (alleged) fathers named at this time are excluded as a possible father
to the child(ren) in question, my TANF benefits will be sanctioned and my case will be closed.

5. I understand that the TANF sanction will only be lifted once the Court has entered an order
establishing paternity and child support for the child(ren) listed on this case.

6. I understand that if a case is filed with the Court that the information filed will be available to all
participants in the case, and the public at large.

I have read the above statements and fully understand the contents of each statement
above. I affirm under the penalties of perjury that the foregoing representations are
true.
Signature of Applicant: ____________________________________

Witness: _______________________________________________

Date: _______________

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