CS_300EZ

APPLICANT IS ►

Relation to Child(ren):

Other

SELECT ONE ROLE TYPE:

Person Receiving Support/Custodian

Person Paying Support/Non-Custodian

Alleged Father

PERSON RECEIVING SUPPORT/CUSTODIAN INFORMATION

Social Security Number (SSN):

In the United States, a Social Security Number is a nine-digit number issued to citizens, permanent residents, and temporary working residents.

Name: Last

Middle

First

Date of Birth

Address (Include Street Name, Apartment Number and/or Floor Number)

If not a United States or US Address, enter Country, Street Name, and Apartment Number and/or Floor Number here. Can also attach a file with your address at the end of the form.

City

State

Zip Code

Phone Number - Home (Include Area Code)

Phone Number - Work (Include Area Code)

Phone Number - Cell (Include Area Code)

Message Phone Number (Include Area Code)

Race

Male/Female

Email Address

PERSON PAYING SUPPORT/NON-CUSTODIAN/ALLEGED FATHER INFORMATION

Person Paying Support:

Other

Social Security Number (SSN):

In the United States, a Social Security Number is a nine-digit number issued to citizens, permanent residents, and temporary working residents.

Name: Last

Middle

First

Alias

Date of Birth

Address (Include Street Name, Apartment Number and/or Floor Number)

If not a United States or US Address, enter Country, Street Name, and Apartment Number and/or Floor Number here. Can also attach a file with your address at the end of the form.

City

State

Zip Code

Date Address Last Known

Phone Number - Home (Include Area Code)

Phone Number - Work (Include Area Code)

Phone Number - Cell (Include Area Code)

Message Phone (Include Area Code)

Email Address

Race

Male/Female

Height

Weight (Pounds)

Hair Color

Eye Color

Birthplace: City

State

Employer Name

Employer Address (provide complete street address or PO Box, City, State, and Zip Code)

Dates Worked: From

Is it possible that another man, other than the alleged father, might be the father of the child(ren) listed?

YES

IF YES,

Name: Last

Middle

First

Address: Street

City

State

Zip

Phone Number (Include Area Code)

Click on + symbol to add more alleged fathers

CHILDREN TO CUSTODIAL/NON-CUSTODIAL/ALLEGED FATHER

Child's SSN

In the United States, a Social Security Number is a nine-digit number issued to citizens, permanent residents, and temporary working residents.

Name: Last

First

Middle

Date of Birth

County of Birth

State of Birth

Race

Male/Female

Click on + symbol to add more children

Do all of the children listed on this application live with you now?

YES

TYPE OF CHILD SUPPORT SERVICES YOU WANT

(check the box next to the service(s) you are requesting):

ESTABLISH AND/OR ENFORCE CHILD SUPPORT AND MEDICAL SUPPORT - FSD will try to establish paternity, get an order for child support and/or medical support (if needed), and enforce child and medical support.

ESTABLISH AND/OR ENFORCE MEDICAL SUPPORT - FSD will try to establish paternity, get an order for medical support (if needed), and enforce medical support coverage for your child(ren).

REVIEW AND MODIFICATION - FSD will review your existing support order and modify the order, if appropriate. This may include updating the order to get medical support for your child(ren). FSD will also provide services shown under Establish and/or Enforce Child Support and Medical Support.

CONSENT AND SIGNATURE

I certify that all information provided is true and complete to the best of my knowledge
I authorize the Family Support Division to get information contained in my child(ren)’s birth certificate file or record. This may include a copy of an acknowledgment of paternity completed by the parents.
I must provide my Social Security number (SSN) and the SSN for each child(ren) per section 466(a)(13) of the Social Security Act and also provide the SSN of the other parent if I know it.
By signing this application on paper or electronically, I am giving the Family Support Division (FSD) permission to deliver, or cause to be delivered, phone calls or text messages to me regarding my case from an automated dialing system at my primary number. The FSD does not use an encryption system when sending text messages. Such unencrypted systems are not secure and carry some level of risk that text messages could be read by a third party.
By signing, I am affirming that I nevertheless prefer to receive text messages from FSD and understand I do not have to consent to this as part of my application and can opt out of getting these calls or text messages by checking “No” in the “Accept Text Messages” box below.

Accept Text Messages

YES

I certify under the penalties of perjury set forth in Section 575.040, RSMo, that my statements contained herein are true and correct to the best of my knowledge.

Applicant Signature

Date

If domestic violence is not an issue for you and/or your child(ren), you don't need to fill out this section.

Have you had problems with your current or past spouse or significant other? Are you afraid that person will hurt you or your children if you receive services from the Family Support Division (FSD)?

If the answer to one of the above questions is “Yes,” FSD may have information that will help you.

If you would like more information about domestic violence services, please check the appropriate box(es) below and return this form with your completed application for services or contact your local FSD office.

It is safe for you to call me during the day at:

Phone Number (Include Area Code)

You can leave a message for me at:

Phone Number (Include Area Code)

It is not safe for you to call me. I will contact you within seven days.

I understand that if I do not contact you within seven days, you will enter the address shown on the application. into your system and use it as my contact address. However, FSD will also take action to prevent this address from being released to the other parent.

Other

My name is:

My Social Security Number is:

In the United States, a Social Security Number is a nine-digit number issued to citizens, permanent residents, and temporary working residents.

We need your Social Security number in order to identify you properly in our records. You do not have to provide this information, but failure to do so may prevent us from promptly or properly identifying you.

You will receive a notice of case opening from FSD and information on how to inquire about your case.
Support payments you may receive from the Family Support Payment Center or the State of Missouri will be issued on a prepaid card, providing a safe and convenient way for you to receive payments (please note, this is not a credit card).
If you would like to have support payments deposited directly into your bank account, call 800-859-7999 or visit dss.mo.gov/cse for information on how to get direct deposit.

For more information about your rights and responsibilities, FSD’s fees and distribution policies or for more information about FSD’s child support services or other FSD services, visit our website at www.dss.mo.gov/cse/index.htm or call the FSD Customer Service Center at 866-313-9960.

Once FSD opens your case, you can choose to withdraw your request for services by sending a written request to FSD, PO Box 6790, Jefferson City, MO 65102–6790.

You may need to provide supporting documents, such as Court Order, Birth Certificates, Paternity Affidavits, etc. Please click “Attach” to select and upload them now.

Supported file types are accepted: Audio, Video, Image, Text, and Application PDFs.

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