LaGrange County Child Support

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Indiana Child Support Services Enrollment

State Form 34882 (R17 / 3-20) / CSB 425A
DEPARTMENT OF CHILD SERVICES

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 parties 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 is protected to prevent unauthorized disclosure.
ENROLLEE INFORMATION
Last name
First name
Middle name
Suffix (Jr., III, etc.)

Other names used
Relationship to dependents on this form
(mother, father, guardian, other)
Do you have primary physical custody of dependents on this form?
Date of birth (mm-dd-yyyy)
Gender
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)
Telephone number (cellular)
Telephone number (home)
Telephone number (work)
E-mail address

Do you need special assistance? (If yes, complete next box.)
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)?
(If yes, your case worker may discuss additional protections offered when providing child support services.)

Do either of the following apply?
Are you currently employed? (If yes, complete the next two boxes.)
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
Do you have a private attorney handling paternity and/or support matters for dependents listed in this form? (If yes, complete next box.)
Name of attorney (full name)
Are you applying for services for an unborn child? (If yes, complete next box.)
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
Race
Social Security Number / ITIN
Has paternity been established for this child? (If yes, then complete the next two boxes.)
How was paternity established? (If by court order, complete the next box.)
Where was paternity established? (County and state)
Is there a court ordered child support obligation for this dependent? (If yes, complete the next box.)
Where was child support ordered? (County and state)
Enrolled in Medicaid?
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
Race
Social Security Number / ITIN
Has paternity been established for this child? (If yes, then complete the next two boxes.)
How was paternity established? (If by court order, complete the next box.)
Where was paternity established? (County and state)
Is there a court ordered child support obligation for this dependent? (If yes, complete the next box.)
Where was child support ordered? (County and state)
Enrolled in Medicaid?
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
Race
Social Security Number / ITIN
Has paternity been established for this child? (If yes, then complete the next two boxes.)
How was paternity established? (If by court order, complete the next box.)
Where was paternity established? (County and state)
Is there a court ordered child support obligation for this dependent? (If yes, complete the next box.)
Where was child support ordered? (County and state)
Enrolled in Medicaid?
OTHER PARENT 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?
Other names used
Date of birth (mm-dd-yyyy)
Gender
Race
Social Security Number / ITIN
Height
Weight
Hair Color
Other distinguishing characteristics (eye color, tattoos, etc.)
Home address (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.)
Specify assistance needed here (physical, hearing impaired, language interpreter, other)
Do either of the following apply?
Current or last known employer
Employer telephone number
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 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 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 noncooperation 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.
Printed name of parent / guardian (if enrollee is an unemancipated minor)
Signature of parent / guardian (if enrollee is an unemancipated minor)
I agree that if I am overpaid, the state may recoup the amount of the overpayment from future child support payments owed to me.
Printed name of enrollee
Signature of enrollee
Date Signed (mm-dd-yyyy)
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)


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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
     


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