LaGrange County Child Support
Powered By SBS Portals
Indiana Child Support Services Enrollment
State Form 34882 (R19 / 6-25)
DEPARTMENT OF CHILD SERVICES
INSTRUCTIONS:
Complete this form by providing the requested information.
Take or mail the signed form to your County Child Support Office.
NOTICE TO ENROLLEE
All custodial parties and non-custodial parents may enroll to receive child support services. There is no enrollment fee or residency requirement.
When enrolling the following Child Support Services are
ALL
included. What service(s) are you expecting to start with (select all that apply)?:
Parent location
Establishment of
Paternity
Child Support
Medical Support
Modification of existing:
Child Support Obligation
Medical Support Obligation
Enforcement of existing:
Child Support Obligation
Medical Support Obligation
Assistance with issuing Income Withholding Orders
Information provided for this enrollment is confidential and is protected to prevent unauthorized disclosure.
ENROLLEE INFORMATION
Last name
First name
Middle name
Suffix (Jr., III, etc.)
Other names used
Relationship to dependents (mother, father, guardian, other)
Date of birth
(mm-dd-yyyy)
Gender
Female
Male
Race
Social Security Number / ITIN
Home address (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Mailing address, if different from address above (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Telephone number (cellular)
Telephone number (home)
Telephone number (work)
E-mail address
Do you need special assistance? (If yes, complete next box.)
No
Yes
Specify assistance needed here (i.e., physical, hearing impaired, language interpreter, other)
Do you believe that pursuing child support services may result in physical or emotional harm to you or your child(ren)?
No
Yes
(If yes, your case worker may discuss additional protections offered when providing child support services.)
Do either of the following apply?
Active Military Duty
Currently Incarcerated
Are you currently employed? (If yes, complete the next two boxes.)
No
Yes
Name of employer
Address of employer (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Marital status of enrollee to other parent
Never married
Married or Previously Married (Date of Marriage: if checked, complete next box)
If Married or Previously Married to the other parent are you currently?
Separated with no court orders entered
Divorce or legal separation filed: Cause Number, County and State of filing
Do you have a private attorney handling paternity and/or support matters for dependents listed in this form? (If yes, complete next box.)
No
Yes
Name of attorney (full name)
Are you applying for services for an unborn child? (If yes, complete next box.)
No
Yes
Due date
(mm-dd-yyyy)
DEPENDENT #1 INFORMATION
Last name
First name
Middle name
Suffix (Jr., III, etc.)
Date of birth
(mm-dd-yyyy)
Place of birth (City and State)
Gender
Female
Male
Race
Social Security Number / ITIN
Who does dependent reside with?
No
Unknown
Yes
If other: Please provide name of person
Dependent enrolled in Medicaid?
No
Unknown
Yes
Name of person ordered to pay
Is someone listed as father on birth record?
No
Unknown
Yes
How was Father determined? (If Court Order or Marriage complete next box)
Court Order
Marriage
Paternity Affidavit
In what county and state did Order or Marriage occur?
Is someone ordered to pay child support for this dependent? (If yes, complete the next box.)
No
Unknown
Yes
What county and state was child support ordered?
DEPENDENT #2 INFORMATION
Last name
First name
Middle name
Suffix (Jr., III, etc.)
Date of birth
(mm-dd-yyyy)
Place of birth (City and State)
Gender
Female
Male
Race
Social Security Number / ITIN
Who does dependent reside with?
No
Unknown
Yes
If other: Please provide name of person
Dependent enrolled in Medicaid?
No
Unknown
Yes
Name of person ordered to pay
Is someone listed as father on birth record?
No
Unknown
Yes
How was Father determined? (If Court Order or Marriage complete next box)
Court Order
Marriage
Paternity Affidavit
In what county and state did Order or Marriage occur?
Is someone ordered to pay child support for this dependent? (If yes, complete the next box.)
No
Yes
What county and state was child support ordered?
DEPENDENT #3 INFORMATION
(Attach separate page with information requested below for all additional dependents.)
Last name
First name
Middle name
Suffix (Jr., III, etc.)
Date of birth
(mm-dd-yyyy)
Place of birth (City and State)
Gender
Female
Male
Race
Social Security Number / ITIN
Who does dependent reside with?
No
Unknown
Yes
If other: Please provide name of person
Dependent enrolled in Medicaid?
No
Unknown
Yes
Name of person ordered to pay
Is someone listed as father on birth record?
No
Unknown
Yes
How was Father determined? (If Court Order or Marriage complete next box)
Court Order
Marriage
Paternity Affidavit
In what county and state did Order or Marriage occur?
Is someone ordered to pay child support for this dependent? (If yes, complete the next box.)
No
Yes
What county and state was child support ordered?
OTHER PARTY INFORMATION
(Attach separate page with information requested below for all additional parents, or additional potential parents if paternity has not been established.)
Last name
First name
Middle name
Suffix (Jr., III, etc.)
Relationship to dependents on this form (mother, father, potential father, guardian, other)
Does this parent have primary physical custody of dependents on this form?
No
Yes
Other names used
Date of birth
(mm-dd-yyyy)
Gender
Female
Male
Race
Social Security Number / ITIN
Height
Weight
Hair Color
Other distinguishing characteristics (eye color, tattoos, etc.)
Current or last known home address (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Mailing address, if different from address above (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
Telephone number (cellular)
Telephone number (home)
Telephone number (work)
E-mail address
Does this parent need special assistance? (If yes, complete next box.)
No
Yes
Specify assistance needed here (physical, hearing impaired, language interpreter, other)
Do either of the following apply?
Active Military Duty
Currently Incarcerated
Current or last known employer
Employer telephone number
Does this parent have a private attorney handling paternity and/or support matters for dependents listed in this form? (If yes, complete next box.)
No
Yes
Name of attorney (full name)
Address of employer (Full address including number and street, Rural Route number, Apartment or Room number, city, state, and ZIP code)
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 parenting time or 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, in accordance with IC 31-25-4-13.1(e), 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. No attorney/client relationship is created based on the submission of the enrollment form and neither the Child Support Bureau nor the County Child Support Office will represent me in any legal action. In accordance with IC 31-25-4-13.1(f)(2), communications between the enrollee or other participants and the Child Support Bureau of 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 that 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 INSCCU for payment of support on my child support case.
I understand that failure to provide all requested information may result in a delay in establishment or enforcement of my child support case.
Printed name of parent / guardian (if enrollee is an unemancipated minor)
Signature of parent / guardian (if enrollee is an unemancipated minor)
Click here to sign
I agree that if I am overpaid, the state may recoup the amount of the overpayment from future child support payments owed to me.
No
Yes
Printed name of enrollee
Signature of enrollee
Click here to sign
Date Signed
(mm-dd-yyyy)
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)
Enter the code here
Office of the Prosecuting Attorney, 105 N High St, 2nd Floor, LaGrange, IN 46761 | P: (260) 499-6326 | F: (260) 499-6402
www.www.lagrangecounty.org
