Oneida Nation

Child Support Agency Guardian Application for Service


Information provided on this form (including attachments) may only be shared with others for the purpose(s) of the administration of the child support program and other related programs.


Section A

Requested Services From Child Support Agency

Services Requesting:
Are you applying for services for an unborn child?:
Are you requesting genetic testing?:

Section I - Guardians Information

Guardian: Information

Guardian Name :   

Guardian: Maiden Name or Alias:

Guardian: Social Security Number:
Guardian: Gender:
Guardian: Contact Phone:
Guardian: Email Address:

Guardian: Home Address Guardian: Mailing Address
Guardian: Address:
Guardian: City:
Guardian: State:
Guardian: Zip:
Guardian: Is Mailing Address Different from Above?:
Guardian: Mailing Address:
Guardian: Mailing City:
Guardian: Mailing State:
Guardian: Mailing Zip:

Guardian: Enrollment Information

Guardian Is A Tribal Member?: Guardian: Tribal Affiliation: Guardian: Enrollment Number:

Guardian: Background Information

Guardian: Has a disability:
Describe Guardians Disability:

Guardian: Relationship to child(ren):
Guardian: Please check services receiving or have received:

Guardian: Do you have a court order awarding you placement?:
Court or Tribe that awarded you placement:

Section II - Mothers Information

Mother: Information

Mothers Name :   

Mother: Maiden Name or Alias:

Mother: Social Security Number:
Mother: Contact Phone:
Mother: Email Address:

Mother: Home Address Mother: Mailing Address
Mother: Address:
Mother: City:
Mother: State:
Mother: Zip Code:
Mother: Is Mailing Address Different from Above?:
Mother: Mailing Address:
Mother: Mailing City:
Mother: Mailing State:
Mother: Mailing Zip Code:

Mother: Enrollment Information

Mother is a Tribal Member?: Mother: Tribal Affiliation: Mother: Enrollment Number:

Mother: Place of Birth

Mother: Birth City: Mother: Birth State:
Mother: Birth County: Mother: Birth Country:

Mother: Background Information

Mother of child(ren) has a disability?:
Describe Mothers Disability:

Mothers current relationship to the Father:
Mother: Please check services receiving or have received:

Mother: Employment Information

Mother: Is Employed:

Mother: Employer: Mother: Work Phone:
Mother: Employer Address:
Mother: Job Title:
Mother: Hourly Wages: Mother: Hours Per Week: Mother: How often are you paid?:
Mother: Occupational / Professional License Required: Mother: Type of license:
Mother: Health Insurance Available: Mother: Are the children covered?: Mother: Insurance Premium:

Mother: Military Background

Mother: Member of the Armed Forces: Mother: Duty Status: Mother: Veterans Benefits:
Mother: Branch:

Section III - Fathers Information

Father: (Not Husband)

Is the Father of the Child Married to the Mother:

Name:      
Social Security Number:

Address:

Father: Information

Fathers Name :   

Father: Alias:
Father: Social Security Number:

Father: Contact Phone:
Father: Email Address:

Father: Home Address Father: Mailing Address
Father: Home Address:
Father: City:
Father: State:
Father: Zip Code:
Is Fathers Mailing Address Different from Above?:
Father: Mailing Address:
Father: Mailing City:
Father: Mailing State:
Father: Mailing Zip Code:

Father: Enrollment Information

Father is a Tribal Member?: Father: Tribal Affiliation: Father: Enrollment Number:

Father: Place of Birth

Father: Birth City: Father: Birth State:
Father: Birth County: Father: Birth Country:

Father: Background Information

Father of child(ren) has a disability:
Describe Fathers Disability:

Fathers current relationship to the Mother:
Father: Please check services receiving or have received:

Father: Employment Information

Father: Is Employed:

Father: Employer: Father: Work Phone:
Father: Employer Address:
Father: Job Title:
Father: Hourly Wages: Father: Hours per week worked: Father: How often are you paid?:
Father: Occupational / Professional License Required: Father: Type of license:
Father: Health Insurance Available: Father: Are the children covered?: Father: Insurance Premium:

Father: Military Background

Father: Member of the Armed Forces: Father: Duty Status: Father: Veterans Benefits:
Father: Branch:

Father: Unknown Location

Is the Fathers Location Known?:
Distinguishing marks, tattoos, scars, or birthmarks:

Height: Weight: Hair Color:
Eye Color: Race:  
Has this parent ever been arrested or convicted of a crime?:
City of Conviction: State of Conviction:
Does the father have other children? :  

Section IV - Child(ren) Information

Section V - Additional Information

Attachments:

Additional Information:

TAX INTERCEPT INFORMATION: I understand that the Oneida Nation Child Support Agency will submit any certifiable past-due child support debts to the State of Wisconsin tax/lottery intercept programs. I understand that I am applying for State IV-D services for purposes of submitting arrearages for Federal tax refund intercept programs. I understand that if I receive the other parent's intercepted tax refund money that is later recalled by the federal Internal Revenue Service (IRS) or the state Department of Revenue (DOR), I must immediately
return the money. If I cannot repay all the money at once, I will follow a payment plan until the amount is repaid in full. (If the tax refund is recalled, you will receive a letter with information about how to return the money and how to set up a payment plan.

CHILD SUPPORT ORDERS: I understand that the law does not permit percentage orders in child support agency cases.

If I am opening a new child support case or reopening a closed child support case with the child support agency and have a percentage order, I understand that the child support agency is not responsible for reconciling the order.

The child support agency is required to change the percentage order into a dollar amount order. By submitting this application, I am agreeing to cooperate with the agency in changing the order. Disclaimer: The Oneida Nation will bring any necessary administrative or court actions to establish paternity (legal fatherhood) or to establish or enforce a support order. However, the child support attorney does not represent either parent but rather represents the Oneida Nations' interest in enforcing support.

I hereby request child support services under the Child Support Enforcement Program under Title IV-D of the Social Security Act. I understand that I must cooperate with the child support agency by providing information that affects my case and by keeping my appointments with the agency.

Full Legal Name:

Leave this empty:

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Signature Certificate
Document name: Child Support Agency Guardian Application for Service
lock iconUnique Document ID: 6fa561e61497b8ea017de015265ac67777b9e2f4
Timestamp Audit
February 15, 2021 10:02 am CDTChild Support Agency Guardian Application for Service Uploaded by Josh Swanson - jswanson@oneidanation.org IP 74.62.93.28
February 15, 2021 10:55 am CDTCC Message - jswanson@oneidanation.org added by Josh Swanson - jswanson@oneidanation.org as a CC'd Recipient Ip: 74.62.93.28
February 15, 2021 1:07 pm CDTCC Message - jswanson@oneidanation.org added by Josh Swanson - jswanson@oneidanation.org as a CC'd Recipient Ip: 74.62.93.28
February 15, 2021 1:12 pm CDTGuardian Application for Service - strongfamily@oneidanation.org added by Josh Swanson - jswanson@oneidanation.org as a CC'd Recipient Ip: 74.62.93.28
March 9, 2021 9:01 am CDTGuardian Application for Service - strongfamily@oneidanation.org added by Josh Swanson - jswanson@oneidanation.org as a CC'd Recipient Ip: 74.62.93.28
March 9, 2021 11:43 am CDTGuardian Application for Service - strongfamily@oneidanation.org added by Josh Swanson - jswanson@oneidanation.org as a CC'd Recipient Ip: 74.62.93.28