APPLICANT INSTRUCTIONS Thank you for applying for child

Revised April 2019

APPLICANT INSTRUCTIONS

Thank you for applying for child support services. To offer Same Day Services (SDS), please provide

detailed information to help us assist in processing your application. If you receive TANF/Medicaid

services, please call the DCSS Contact Center for further assistance (number listed below).

Applicant must provide at least one form of photo identification, for example:

Valid driver’s license;

Any other international government, federal government, state government and local

government-issued picture/photo ID including a Green Card or Visa;

Valid Passport.

Applicants MUST submit the following with the application:

Birth certificates for all children born OUTSIDE of Georgia;

Paternity Affidavit;

Proof of RSDI dependent benefits received;

Signatures on all pages and notarize forms where required;

Verification of school enrollment, status, grade level and anticipated graduation date if the

child(ren) is 18 and is still a full-time high school student and the court order addresses child

support beyond the age of 18, if applicable;

A photocopy of all support orders that exist (Final Divorce Decree, Separation or Settlement

Agreement, Child Support Order entered by any state or foreign country, Modification of

Support Order, Contempt Order, Juvenile Court Order and/or Temporary Order). Exception:

A certified copy of the most recent order setting the support obligation is required if the order

must be registered for enforcement in another state or foreign jurisdiction, before DCSS can

process a UIFSA action;

The following documents are preferred when applying for services:

Proof of physical custody of a minor child or dependent child;

Current income information (i.e. check stubs, W-2’s, or Tax Statements for past 3 years with

1099s if self-employed and a completed financial affidavit);

Birth Certificates for all children born in Georgia;

Social Security cards for all children listed in the application (if available);

Receipts/verification of medical, vision, dental, life insurance, deductibles and co-pays,

if applicable;

Extraordinary educational expense information for tuition, room & board, fees, books,

if applicable; and

Child rearing expenses for music/art lessons, travel, band, clubs, and athletics, if applicable.

Authorization Agreement for Direct Deposit of Child Support Payments if direct deposit is being

requested and a voided check or savings account deposit slip.

Note: Please call the DCSS Contact Center toll-free at 1-844-MYGADHS (1-844-694-2347 Toll Free) if:

• You speak another language other than English in your home and need assistance,

• You have a disability and need assistance or accommodations to visit our office; or

• You are deaf or hearing impaired and need the assistance.

If you are a TTY (text telephone) user you may contact our office through the Georgia Relay Service at 7-1-1

Note: If possible, please make copies of important information and your entire application before

visiting our office to retain for your records.

State of Georgia Local Office Stamp

Department of Human Services

Division of Child Support Services

Revised April 2019

Applicant Rights and Responsibilities

I understand and agree that:

Initial All:

_____ The Division of Child Support Services (DCSS) has the authority under federal and state law

to take any legal action that is necessary to establish paternity and to establish, modify and/or

enforce an obligation for child support including medical support. DCSS does not guarantee that

efforts on my behalf will be successful as actions taken by DCSS may be subject to the discretion of

the judge.

_____ If I should receive payments distributed to me in error (overpayments), I will be notified in

writing to establish a Recoupment Repayment Installment Plan with DCSS. I understand that my

failure to respond timely to the third and “Final Notice” from DCSS shall serve as my permission for

DCSS to recoup payments from any future child support due to me and I will be subject to

interception of my state income tax refund.

_____ If the person I named as the father of my child(ren) is excluded through paternity testing, I will

be responsible for reimbursing DCSS for the cost of the test.

_____ I must submit myself and/or the child (ren) to genetic testing, as it relates to establishing

paternity, if needed. Genetic test results will not be provided without prior written authorization to

release such information.

_____ My case and current/arrears accounts will not be eligible for closure until all debts owed to the

state, including fees and TANF arrears, are paid in full. If I fail to pay any fees and/or debts owed by

me to DCSS I will be subject to interception of my state income tax refund.

_____ Overpayments of the support ordered amount will be applied first to the past due amounts

and then may be held by DCSS for future payments.

_____ DCSS may use an attorney to establish, enforce and/or modify my child support order. There

is no attorney-client relationship between me and the attorney, as the attorney represents the State.

I understand that the attorney does not handle legal issues such as legitimation, custody or

visitation; therefore, I must seek my own private attorney regarding these issues.

_____ DCSS has provided me with a HIPAA Notice of Privacy Practices. The notice includes an

explanation of how medical information related to my application for services may be used by DCSS,

as well as my right to have access to this medical information. I understand that DCSS will not

share any information unless I provide a written authorization requesting information.

_____DCSS will not release any confidential, personal information to any third parties without my

prior written authorization to release such information.

_____ DCSS does not discriminate on the basis of race, color, national origin, sex, age, religion,

political beliefs or disability. Should I have concerns about my case, I may file a formal complaint

with the local office manager that will result in an internal management review.

_____ When applying for services as a payee, I must have legal or physical custody of a minor child.

In the event that the custody of the child changes, the ordered child support may be redirected to the

new custodian.

_____ I must notify DCSS of any changes to my name, address, phone number(s) or any other

information that is needed to properly manage and/or enforce my case, including but not limited to,

notifying DCSS that I have applied for Temporary Assistance For Needy Families (TANF) benefits. I

understand that failure to keep information up to date may affect DCSS ability to distribute payments

in a timely manner.

Revised April 2019

_____ I must notify DCSS if I have an active child support case with any other state agency, private

attorney or a private collection agency for the child (ren) listed on the application.

_____ A $25.00 non-refundable application fee is required when applying for services unless the

child(ren) or I receive Temporary Assistance for Needy Families (TANF) or Family Medical

Assistance (Medicaid). The fee will be required if only the child(ren) receive Medicaid or I re-apply

for services after requesting case closure or if my case is closed by DCSS due to my non-

cooperation.

_____ A $35 Annual Maintenance Fee will be charged to each case where an applicant has never

received TANF and for whom the State has collected at least $550.00 of support.

_____ Child support payments must be sent to the Family Support Registry and that I should not

accept direct payments from the Non-Custodial Parent (NCP). If I accept payments from the NCP

DCSS may close my case for non-cooperation.

_____ Upon written notification from DCSS, my case may be closed if I fail to cooperate. Prior to

case closure, I must repay any outstanding debts, including fees and overpayments that are owed at

the time and repay any expenses incurred on my behalf. If my case is closed due to severe non-

cooperation, I will not be able to reopen my case or re-apply for services for a minimum period of six

(6) months from the date my case was last closed.

_____ If I request case closure during a legal proceeding to establish or enforce a support order and

my case is eligible for closure, DCSS will not close my case until all legal actions have been

completed and all fees/debts owed to the state are paid in full.

_____ Federal law authorizes DCSS to charge an individual who has applied for child support

services and who has never or is no longer receiving TANF assistance a fee for the offset of state

and federal taxes. In the event that an offset is received, an administrative fee of $12.00 per state

offset and $25.00 per federal offset may be assessed to my case.

_____ I authorize DCSS to send correspondence electronically, including via email, text messages,

and other methods. To ensure confidentiality of such correspondence, I understand that it is my

responsibility to provide a secure and active email address and mobile phone number.

_____ I may obtain my case and payment information by calling the Contact Center at 1-844-

MYGADHS (1-844-694-2347 Toll Free) or I may view my case information on the Customer Service

Online website at https://services.georgia.gov/dhr/cspp/do/Logon.

I have received and read all program information describing available services, fees, as well as my

rights and responsibilities. I have the right to ask questions before I submit my application. My

signature on this document authorizes the Division of Child Support Services to provide necessary

and appropriate services on my behalf. I certify that all of the information supplied by me in my

Portal application is true and correct to the best of my knowledge and belief. I understand the

criminal penalties for making false statements and false swearing under O.C.G.A. §16-10-71 and do

hereby attest to the truthfulness of the information provided.

________________________________________ ___________________________________

Name of Applicant (Please Print Clearly) Signature of Applicant

________________________________________ _________________________________

Witness Date

Applicant’s Email address is: (Please Print Clearly) _______________________________________

Revised April 2019

Application for Services

PLEASE CHECK ONE

I AM THE: Custodial parent [ ] Noncustodial parent [ ] Nonparent Custodian [ ] Alleged Father [ ]

TYPE OF SERVICE REQUESTED (check which applies)

All services available for support [ ]

TANF HISTORY (check all that apply):

I have never received TANF benefits [ ] I currently receive TANF benefits [ ] I currently receive Medicaid Only [ ]

Formerly on TANF [ ]: Received from ______________ to _______________

CUSTODIAL PARENT/NONPARENT CUSTODIAN INFORMATION

Name:

Last First Middle Maiden Name

Social Security Number:

Date of Birth:

Place of Birth:

Sex: Male [ ] Female [ ]

Have you ever had a child support case in another state? [ ] Yes [ ] No

Check all that apply.

Race: [ ] AI-American Indian, Alaskan Native(N) [ ] FP–Filipino(F) [ ] OA–Other Asian(A) [ ] UN–Unknown(U)

[ ] AS-Asian Indian(I) [ ] GC–Guamian or Chamorro(G) [ ] OT–Other, Mixed or Multiple(M) [ ] VT–Vietnamese(V)

[ ] BL-Black or African American(B) [ ] JP–Japanese(J) [ ] PE–Persian(R) [ ] WH–White(W)

[ ] CH-Chinese(C) [ ] KO–Korean(K) [ ] PI–Other Pacific Islander(X)

[ ] EA-East Asian (E) [ ] NH–Native Hawaiian(P) [ ] SA–Samoan(S) [ ] Choose not

to answer

Ethnicity: [ ] CB-Cuban(F) [ ] CH-Chicano/a(CH) [ ] MA-Mexican – American(W) [ ] ME-Mexican(M)

[ ] NH-Not Hispanic or Latino(N) [ ] OT-Other Latino / Hispanic [ ] PR-Puerto Rican(P) [ ] UN-Unknown(U)

[ ] Choose not to answer

Marital Status: Single [ ] Married [ ] Separated [ ]

Divorced [ ] Divorced on: ___/___/___

If married, current spouse’s name:______________________________________

Date of Marriage: ___/___/___

Home Address:

Street Address City, County State, Zip

Mailing Address:

Street Address / P.O. Box City, State Zip

May be contacted at work? [ ] Yes [ ] No

E-Mail Address:

Work Phone:

Home Phone:

Cellular Phone:

Is the custodial parent/nonparent custodian in the military? [ ] Yes [ ] No If so, name the Military Branch: [ ] Retired Military

INSURANCE INFORMATION FOR CUSTODIAL PARENT

Do you currently have health insurance? [ ] Yes [ ] No

If yes, is the minor child you are applying for child support services covered in

this Policy? [ ] Yes [ ] No

Insurance Co. Name:

Phone No.:

Policy No.:

Group#:

DOMESTIC VIOLENCE

Have you ever been a victim of domestic violence? [ ] Yes [ ] No

Has the child(ren) you are requesting services for ever been a victim any physical or emotional harm? [ ] Yes [ ] No

If yes to either or both of the above questions, describe your concerns and/or attach supporting documentation to support your claim on the application.

Under Georgia Law, O.C.G.A. §19-11-30 and §19-11-131, the DCSS will not release any information that would place you or your children at risk

of physical or emotional harm. In such instances, a Family Violence Indicator will be activated on your child support case.

Your case will then be coded to ensure that no information is released to any other state or foreign jurisdiction that may place you or your child(ren) at risk.

Revised April 2019

CHILDREN FOR WHOM YOU NEED SERVICES

Race Codes: Enter the “Race Code” for each child in the appropriate box.

Code

Race

Code

Race

Code

Race

Code

Race

AI

AS

BL

CH

EA

American Indian, Alaska Native(N)

Asian Indian(I)

Black or African American(B)

Chinese(C)

East Asian(E)

FP

GC

JP

KO

NH

Filipino(F)

Guamian /Chamorro(G)

Japanese(J)

Korean(K)

Native Hawaiian(P)

OA

OT

PE

PI

SA

Other Asian(A)

Other, Mixed /Multiple(M)

Persian(R)

Other Pacific Islander(X)

Samoan(S)

UN

VT

WH

NA

Unknown(U)

Vietnamese(V)

White(W)

Choose not to answer

Ethnicity Codes: Enter the” Ethnicity Code (Ethn)” for each child in the appropriate box.

Code

Ethnicity

Code

Ethnicity

CB

CH

MA

ME

NA

Cuban(F)

Chicano/a(CH)

Mexican – American(W)

Mexican(M)

Choose not to answer

NH

OT

PR

UN

Not Hispanic or Latino(N)

Other Latino / Hispanic(O)

Puerto Rican(P)

Unknown(U)

Child’s Name

(Last, First, Middle)

SSN

Date of

Birth

Place of Birth

(City, State)

Sex

M/F

Race

Code

Ethn

Code

Born

Out of

Wedlock

Yes/No

Paternity

Established

by: Court

Order/

Paternity

Test?

Date:

Your relationship to the child (ren): [ ] Biological Mother [ ] Biological Father [ ] Custodian [ ] Nonparent/Relative

[ ] Legal Guardian (proof of guardianship is required) [ ] Other:_________________________________________________________________________

PAYMENT INSTRUCTIONS FOR CUSTODIAL PARENT / CUSTODIAN

Unless a request is made for direct deposit a debit card will be provided for child support payments. If direct deposit is selected, a separate form and

voided check / deposit slip are required.

ALLEGED FATHER / NONCUSTODIAL PARENT INFORMATION

Name:

Last First Middle Maiden Name

Aliases or nicknames:

Social Security Number:

Date of Birth or Age:

Place of Birth:

Sex: Male [ ] Female [ ]

Marital Status: Single [ ] Married [ ] Separated [ ]

Divorced [ ] Divorced on: ___/___/___

If married, current spouse’s name:______________________________________

Date of Marriage: ___/___/___

Eye color:

Hair color:

Weight:

Height:

Check all that apply.

Race:[ ] AI-American Indian, Alaskan Native(N) [ ] FP–Filipino(F) [ ] OA–Other Asian(A) [ ] UN–Unknown(U)

[ ] AS-Asian Indian(I) [ ] GC–Guamian or Chamorro(G) [ ] OT–Other, Mixed or Multiple(M) [ ] VT–Vietnamese(V)

[ ] BL-Black or African American(B) [ ] JP–Japanese(J) [ ] PE–Persian(R) [ ] WH–White(W)

[ ] CH-Chinese(C) [ ] KO–Korean(K) [ ] PI–Other Pacific Islander(X)

[ ] EA-East Asian (E) [ ] NH–Native Hawaiian(P) [ ] SA–Samoan(S) [ ] Choose not to answer

Revised April 2019

Ethnicity: [ ] CB-Cuban(F) [ ] CH-Chicano/a(CH) [ ] MA-Mexican – American(W) [ ] ME-Mexican(M)

[ ] NH-Not Hispanic or Latino(N) [ ] OT-Other Latino / Hispanic [ ] PR-Puerto Rican(P) [ ] UN-Unknown(U)

[ ] Choose not to answer

Mailing Address: [ ] Owns this or

other property

Street Address City, County State, Zip

Is home address [ ]Current or [ ]Last known

Phone Number(s):

Other Possible Address:

Street Address City, State, Zip

Driver’s License #: State:

ALLEGED FATHER / NONCUSTODIAL PARENT EMPLOYMENT

[ ] Employed [ ]Unemployed [ ] Self-employed

Type of Business:

Usual Occupation:

Current or Last Known Employer:

Phone No.:

Dates of employment: ____/____/____ to ____/____/____

Supervisor:

Job title:

Address:

Street Address City County State Zip

Gross income: $ per

Paid: [ ]Weekly [ ]Bi-weekly [ ]Monthly [ ]Semi-monthly

Attach Pay stubs, if possible

INSURANCE INFORMATION FOR ALLEGEDFATHER / NONCUSTODIAL PARENT

Does “alleged” father/NCP currently have health insurance? [ ] Yes [ ] No

If yes, is the minor child you are applying for child support services

covered in this Policy? [ ] Yes [ ] No

Insurance Co. Name:

Phone No.:

Policy No.:

Monthly Premium: $_________________________

Portion Paid for Child: $________________________

OTHER INCOME SOURCES /RESOURCES

Federal Benefits Received: [ ] Social Security [ ] Postal [ ]RR Retirement [ ]Civil Service [ ] Military [ ] VA [ ] Retirement[_] Receives SSI Receiving

Unemployment Benefits? [ ] Yes [ ] No

Receiving Pension Plan benefits? [ ] Yes [ ] No If so, from what company?

Any professional licenses? [ ] Yes [ ] No If so, what type?:

Is the noncustodial parent in the military? [ ] Yes [ ] No If so, name the Military Branch: [ ] Retired Military

INCARCERATION HISTORY

Has the noncustodial parent been: [ ] in Prison [ ] on Probation or has Probation history

If incarcerated please give dates ____/____/____ to ____/____/____

Institution’s name: _____________________________________

Institution’s address or city/state:__________________________________________________________

If on probation or has a probation history please give:

Probation history dates ____/____/____ to _____/____/_____

Probation period to end: ___/___/___

Probation / parole officer's name: _________________________

ALLEGED FATHER / NONCUSTODIAL PARENT FAMILY HISTORY

Mother:

Maiden Name:

Phone #: ( )

Date of Birth:

Place of Birth:

Deceased On: Deceased on:

Address:

Street Address City, State, Zip

Father:

Phone No.:

Date of Birth:

Place of Birth:

Deceased on:

Address:

Street Address City, State, Zip

Other known Relative:

Relationship:

Revised April 2019

Address:

Street Address City, State, Zip

Other contact address (friends, etc):

Name Street Address City, State, Zip

Other contact phone number:

Complete this section ONLY if you are NOT the child(ren)’s Parent

I, _________________________________________________ am the legal custodian of the child(ren) named above. I obtained legal custody for the

child(ren) on / / (proof of guardianship is required). Acceptable legal documents include, but are not limited to, Juvenile Court custody orders,

Superior Court custody orders and Probate Court guardianship orders.

My relationship to the child(ren) is _______________________. The child(ren) came to live with me on (MM/DD/YY): / /

Biological Mother (note if deceased):

Name Address City, County, State, State, Zip Date of Birth SSN

Biological Father (note if deceased):

Name Address City, County, State, State, Zip Date of Birth SSN

________________________________________________________ ___________________________

Signature Date

Under the penalty of perjury, I do hereby swear and affirm that the information I provided on the Application for Child Support Services is

accurate and true to the best of my knowledge. I understand that knowingly making false statements and false swearing is punishable

under Georgia law by a fine up to $1,000, by imprisonment between one and five years, or both. I do hereby attest to the truthfulness of the

information provided.

_______________________________________________________________ _______________________

Applicant Signature Date

For DCSS Office Use Only:

Application Requested Date (required):____/_____/____ Application Provided (date given in person or mailed) (required):___/___/____ Application Provided

by (staff’s first and last name required):_______________________________________

(Note: Federal regulations require an application be provided the same day to individuals who make in person requests or within 5 working days of a written or telephone

request, see 45CFR §303.2(a)(2)).

Date returned to DCSS / / Application Processed Date (required):____/___/______ Processed by (First & Last Name)______________________ $TARS No:

______________________________ Application fee PAID (Y/N): [_ ]; If no, why not?____________________________________________________________________

Revised February 2019

PERSONAL / FINANCIAL AFFIDAVIT

$TARS Case Number: ____________________________________

Non-Custodial Parent Name: ______________________________

Custodial Parent Name: __________________________________

CUSTODIAL PARENT [ ] NON CUSTODIAL PARENT [ ] NON PARENT CUSTODIAN [ ]

PERSONAL INFORMATION:

Your name: ________________________________________ DOB: ________________ Social Security Number:____________________

Other married names, nicknames, etc: __________________________________________________________________________________

Home address:_____________________________________________________________________________________________________

Street Address City State County Zip

ADOPTION / FOSTER CARE:

[ ] Currently receive [ ] Never received [ ] Reunification / Foster Care Plan

How much monthly? $__________________

YOUR EMPLOYMENT:

[ ] Employed [ ] Unemployed [ ] Self-employed Type of Business:___________________________________________________________

Employer: _______________________________________ Job Title:_______________________________________________________

Supervisor:_______________________________________ Work Phone No: _________________________________________________

Employer address: _________________________________________________________________________________________________

Street Address City State County Zip

Employed from ____/____/____ to ____/____/____ [ ] Union:__________________ Local No:_________________________________

GROSS Income: $________ (Attach pay stubs) Pay Frequency: [ ] Weekly; [ ] Bi-weekly; [ ] Monthly; [ ] Semi-monthly

Do you have any Professional licenses: [ ] Yes If so, what type? ___________________ License #:______________________________

NAME OF BANK / CREDIT UNION:

_____________________________________ Account Type [ ] Checking [ ] Savings Acct #:_________________________________

YOUR TANF (WELFARE) HISTORY:

[ ] Never on TANF [ ] Currently on TANF [ ] Formerly on TANF [ ] History Unknown

[ ] Receives Medicaid Only; [ ] Receives Food Stamps only; TANF received from ___/___/___ to ___/___/___

PREVIOUS EMPLOYMENT (LAST 3 YRS):

Provide City, State & Employer Name. Complete addresses are not required.

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

_________________________________________________________________________________________________________________

Employer Name City, State Dates of Employment

EDUCATIONAL HISTORY:

Highest grade level in school you have completed: __________________

Highest degree you have earned: [ ] None [ ] GED [ ] Technical College/AA [ ] College Degree or higher

Last School (High School, Trade, Colleges) attended:

__________________________________________________________________________________________

Name Street City State Zip Phone Number

__________________________________________________________________________________________

Name Street City State Zip Phone Number

Revised February 2019

PRE-EXISTING CHILD SUPPORT ORDERS BEING PAID FOR OTHER CHILDREN:

COURT NAME AND

COURT CASE NUMBER

INITIAL DATE

OF ORDER

NAMES AND BIRTHDATES OF

CHILDREN

IS CHILD

RECEIVING

TANF?

AMOUNT BEING PAID

PAYMENT RECORD

REQUIRED

$

OTHER CHILDREN

NAME __________________________________________ DOB ___/___/___

NAME ________________________________ DOB ___/___/___

YOUR FINANCIAL SUMMARY

Gross Income Source

Averag

e

Monthly

Gross

Amount

Expense Source

Average

Monthly

Gross

Amount

Salary / Wages (do not include TANF)

$

Rent or mortgage payment

$

Commissions, fees & tips

$

Utilities (electric, natural / propane gas,

telephone)

$

Self-Employment Income

[Refer to O.C.G.A. §19-6-15 (f)(1)(B) for details]

$

Child care (proof is required)

$

Alimony Paid (proof is required)

$

Bonuses

$

Food

$

Overtime Payments

$

Medical bills or expenses

(not covered by insurance) (proof is required)

$

Severance Pay

$

Probation / parole fines

$

Recurring income from Pensions or retirement plans

$

Vehicle payment

$

Interest Income

$

Clothing

$

Income from dividends

$

Transportation/Visitation costs (proof is

required)

$

Trust income

$

Child support paid by previous court order

$

Income from annuities

$

Property taxes

$

Capital Gains

$

Recreation

$

Social Security Disability or Retirement

(Do not include SSI or payment for children)

$

Insurance (health) (proof is required)

$

Worker's Compensation benefits

$

Insurance (life) (proof is required)

$

Unemployment Compensation benefits

$

Insurance (automobile, home)

$

Judgments from Personal Injury or other Civil Cases

$

Insurance (Dental/Vision) (proof is required)

$

Gifts (cash or other gifts that can be converted to cash)

$

Bankruptcy

$

Prizes / Lottery winnings

$

Extraordinary Educational Expenses (i.e.,

tuition, books, room & board) (proof is

required)

$

Alimony & maintenance from persons not on this case

$

Assets which are used for support of family

$

Child’s extraordinary medical expenses

(co-pays, deductibles) (proof is required)

$

Fringe Benefits (if significantly reduce living expenses)

$

Any other income including Imputed Income:

(Do not include means-tested public assistance, such as TANF

or Food Stamps)

$

Special expenses for child rearing (i.e., camp,

band, music, art, clubs) (proof is required)

$

Other:

$

TOTAL MONTHLY GROSS INCOME:

$

TOTAL MONTHLY EXPENSES:

$

YOUR ASSETS: (Bank accts, bonds, whole life insurance-cash value CDs, Money Market Accts, property, stocks, vehicles, etc.)

Asset Description

Value

Asset Location / Branch

$

I understand the criminal penalties for making false statements and false swearing under O.C.G.A. §16-10-71 and do hereby attest to the truthfulness of

the information provided. So sworn and affirmed,

Your signature:___________________________________________________________ SSN:___________________ Date:____/____/_____

Notary Public signature: _____________________________________ Commission expiration date: ____/____/_____NOTARY SEAL:

Revised April 2019

Paternity Affidavit

This form is REQUIRED for each child on this case, if any of the following situations apply:

• The child’s parents were not married at the time of conception or birth and paternity has not been established;

• Paternity was established in Georgia (parents were married or signed a Paternity Acknowledgement Form) but is now being

denied or contested;

• Paternity is in doubt for some other reason.

My Name Is ________________________________________________________________ and I am the:

[_] MOTHER, applying for Child Support Services as [_] The Custodial Parent, [_] The Non-Custodial Parent;

[_] NON-Parent Custodian (CU) with custody of the child(ren) (Complete this form to the best of your knowledge);

[_] ALLEGED FATHER, who is applying for Child Support Services as [_] The Non-Custodial Parent, [_] The Custodial Parent.

Child’s Information

Child’s Name as listed

on the Birth Certificate

Child’s Last Child’s First Child’s Middle Child’s Date of Birth

Sex [ ] Male [ ] Female

Social Security Number

Race

Relationship to Applicant for Services

Child was conceived in: City State Country

Name of Hospital where child was born: _________________________________________________________________

City State Country

Name of the child’s father?____________________________

Is his name on the Birth Certificate? [ ] Yes [ ] No

Information About the Relationship Between the Mother and Alleged Father

Mother's Marital Status at child's birth: [ ]Single [ ]Married [ ]Separated [ ]Divorced on _____/____/_____

Husband’s Name: _____________________________________________

I believe _______________________________________________ is the father of my child(ren) because we had sexual contact.

(Name of alleged father)

County in which the child was conceived _____________________________________

Has the mother ever named anyone else as the father of this child? [ ] Yes [ ] No [ ] Unsure

If so, name: Address:

Did the alleged father ever sign a Paternity Statement or Paternity Acknowledgment for this child? [ ] Yes [ ] No

If yes, when: ____/___/____ What State: ____________________

Has the alleged father provided child support, necessities, or gifts for this child? In what way?

Has paternity testing ever been done regarding this alleged father? [ ] Yes [ ] No If yes, attach a copy of the RESULTS

Has paternity testing ever been done on any other man? [ ] Yes [ ] No If yes, attach a copy of the RESULTS

Personally appeared before the undersigned officer, duly authorized to administer oaths, the undersigned who states under oath that

the foregoing statements regarding paternity are true and correct. I understand that medical tests may be required to establish legal

paternity for the above child(ren). My signature on this document authorizes the Division of Child Support Services to provide

necessary and appropriate services on my behalf regarding genetic testing and legal actions to establish paternity for the child(ren).

I certify that all of the information supplied by me is true and correct to the best of my knowledge and belief. I understand the

criminal penalties for making false statements and false swearing under O.C.G.A. §16-10-71 and do hereby attest to the truthfulness

of the information provided.

Printed Name: ____________________________________________

Your Signature: _______________________________________ Date: ____________

Notary Public Signature: ____________________________________ Commission Expiration Date: ______________

NOTARY SEAL DCSS Case Number: «FIELD52»

Revised April 2019

COURT ORDERS, SUPPORT ORDERS, AND ARREARAGE OWED

Note:

Check each type of order. You MUST provide a certified copy of the order(s) to be enforced.

[ ] There is NO Court Order

requiring either parent to pay support for the children of this case, because:

[ ] I am currently married to the NCP (no divorce)

Marriage Date:

Separation Date:

[ ] I was never married to the NCP. (You MUST complete a Paternity Affidavit for each child of this NCP)

[ ] The mother of the child(ren) was married when the

child(ren) was/were born?

Marriage Date:

Separation Date:

[ ] DIVORCE DECREE [ ] DCSS SUPPORT ORDER [ ] LEGITIMATION ORDER [ ] CUSTODY ORDER

Filed in County, State of on [ ] NCP not ordered to pay child support.

Support Ordered Amount: $ per [ ] For each child [ ] For All children

There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit*

[ ] CONTEMPT ORDER [ ] MODIFICATION ORDER [ ] JUVENILE ORDER

Filed in County, State of on [ ] NCP not ordered to pay child support.

Support Ordered Amount: $ per [ ] For each child [ ] For All children

There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit*

[ ] URESA / UIFSA ORDER (support order from another state) Note: We must have certified copies

Filed in County, State of on [ ] NCP not ordered to pay child support.

Support Ordered Amount: $ per [ ] For each child [ ] For All children

There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit*

[ ] TEMPORARY PROTECTIVE ORDER Note: We must have certified copies

Filed in County, State of on [ ] NCP not ordered to pay child support.

Support Ordered Amount: $ per [ ] For each child [ ] For All children

There is an Arrearage (overdue) of $ as of Complete the attached Arrearage Affidavit*

*Notes: Cases with court orders will require an Affidavit of Arrears to be completed.

Any support

NOT

paid through Georgia DCSS will require a

certified

payment history.

PRIVATE CHILD SUPPORT CASE HISTORY

Have you ever had an active child support case with any other state

agency, private attorney or a private collection agency for the child(ren)

listed on this application?

[ ] Yes If so, list below:

Where:

When:

Revised April 2019

ARREARAGE AFFIDAVIT: Please show the total amount of support owed and received in each month. Receipts, canceled

checks, payment records, etc. may be requested to prove the information in this affidavit.

Year

Amount

Year

Amount

Year

Amount

Due

Paid

Due

Paid

Due

Paid

Jan

$

Jan

$

Jan

$

Feb

$

Feb

$

Feb

$

Mar

$

Mar

$

Mar

$

Apr

$

Apr

$

Apr

$

May

$

May

$

May

$

Jun

$

Jun

$

Jun

$

Jul

$

Jul

$

Jul

$

Aug

$

Aug

$

Aug

$

Sep

$

Sep

$

Sep

$

Oct

$

Oct

$

Oct

$

Nov

$

Nov

$

Nov

$

Dec

$

Dec

$

Dec

$

YTD

Total

$

YTD

Total

$

YTD

Total

$

Year

Amount

Year

Amount

Year

Amount

Due

Paid

Due

Paid

Due

Paid

Jan

$

Jan

$

Jan

$

Feb

$

Feb

$

Feb

$

Mar

$

Mar

$

Mar

$

Apr

$

Apr

$

Apr

$

May

$

May

$

May

$

Jun

$

Jun

$

Jun

$

Jul

$

Jul

$

Jul

$

Aug

$

Aug

$

Aug

$

Sep

$

Sep

$

Sep

$

Oct

$

Oct

$

Oct

$

Nov

$

Nov

$

Nov

$

Dec

$

Dec

$

Dec

$

YTD

Total

$

YTD

Total

$

YTD

Total

$

Total Due:$____________ Minus Total Paid:$____________ = Balance Due: $____________ as of

____________.

I certify that all of the information supplied by me is true and correct to the best of my knowledge and belief. I

understand the criminal penalties for making false statements and false swearing under O.C.G.A. §16-10-71 and

do hereby attest to the truthfulness of the information provided.

So sworn and affirmed,

My Signature:______________________________________________________________________ Date: ____________

Notary Public Signature:__________________________________ Commission Expiration Date: ______________

NOTARY SEAL:

Revised April 2019

HIPAA Notice of Privacy Practices

Georgia Department of Human Services

Date: April 8, 2016

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

The Department of Human Services (DHS) is an agency of the Executive Branch of Georgia government

charged with the administration of numerous federal programs responsible for the storage, use and

maintenance of medical and other confidential information. Federal and state laws establish strict

requirements for these programs regarding the use and disclosure of confidential and protected information.

DHS is required to comply with those laws as noted throughout this Notice.

OBLIGATIONS OF THE DEPARTMENT OF HUMAN SERVICES:

DHS is required by law to:

• Maintain the privacy of protected health information;

• Give you this notice of our legal duties and privacy practices regarding health information about you;

and

• Follow the terms of our notice currently in effect.

HOW DHS MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways DHS may use and disclose health information that identifies you (“Health

Information”). Except for the purposes described below, DHS will use and disclose Health Information only

with your written permission. You may revoke such permission at any time by writing to the HIPAA Privacy

Officer at the contact information above.

For Treatment. DHS may use and disclose Health Information for your treatment and to provide you with

treatment-related health care services. For example, DHS may disclose Health Information to doctors, nurses,

technicians, or other personnel who are involved in your medical care and need the information to provide you

with medical care.

For Payment. DHS may use and disclose Health Information so that DHS or others may bill and receive

payment related to your care, an insurance company, or a third party for the treatment and services you

received. For example, DHS may provide your health plan information so that treatment may be paid for.

For Health Care Operations. DHS may use and disclose Health Information for health care operations

purposes. These uses and disclosures are necessary to make sure that quality care is received and to

operate, manage, and administer the functions of the agency. For example, DHS may use and disclose

information to make sure the medical care you receive is of the highest quality. DHS also may share

information with other entities that have a relationship with you (for example, your health plan) for their health

care operation activities.

Revised April 2019

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. DHS may

use and disclose Health Information to contact you to remind you of an appointment with a physician. DHS

also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits

and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, DHS may share Health

Information with a person who is involved in your medical care or payment for your care, such as your family or

a close friend. DHS also may notify your family about your location or general condition or disclose such

information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, DHS may use and disclose Health Information for research. For

example, a research project may involve comparing the health of patients who received one treatment to those

who received another, for the same condition. Before DHS uses or discloses Health Information for research,

the project will go through a special approval process. Even without special approval, DHS may permit

researchers to look at records to help them identify patients who may be included in their research project or

for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. DHS will disclose Health Information when required to do so by international, federal,

state or local law.

To Avert a Serious Threat to Health or Safety. DHS may use and disclose Health Information when

necessary to prevent a serious threat to your health and safety or the health and safety of the public or another

person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. DHS may disclose Health Information to our business associates that perform

functions on our behalf or provide us with services if the information is necessary for such functions or

services. For example, DHS may utilize the services of a separate entity to perform billing services. All DHS

business associates are obligated to protect the privacy of your information and are not allowed to use or

disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, DHS may use or release Health Information to

organizations that handle organ procurement or other entities engaged in procurement, banking or

transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, DHS may release Health Information as

required by military command authorities. DHS also may release Health Information to the appropriate foreign

military authority if you are a member of a foreign military.

Workers’ Compensation. DHS may release Health Information for workers’ compensation or similar

programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. DHS may disclose Health Information for public health activities. These activities

generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report

child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of

products they may be using; a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition; and the appropriate government authority if it is believed a

patient has been the victim of abuse, neglect or domestic violence. DHS will only make this disclosure if you

agree or when required or authorized by law.

Health Oversight Activities. DHS may disclose Health Information to a health oversight agency for activities

authorized by law. These oversight activities include, for example, audits, investigations, inspections, and

licensure. These activities are necessary for the government to monitor the health care system, government

programs, and compliance with civil rights laws.

Revised April 2019

Data Breach Notification Purposes. DHS may use or disclose your Protected Health Information to provide

legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, DHS may disclose Health Information in

response to a court or administrative order. DHS also may disclose Health Information in response to a

subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if

efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. DHS may release Health Information if asked by a law enforcement official if the

information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited

information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a

crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4)

about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises;

and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or

location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. DHS may release Health Information to a coroner or

medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause

of death. DHS also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. DHS may release Health Information to authorized federal

officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. DHS may disclose Health Information to authorized

federal officials so they may provide protection to the President, other authorized persons or foreign heads of

state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a

law enforcement official, DHS may release Health Information to the correctional institution or law enforcement

official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect

your health and safety or the health and safety of others; or (3) the safety and security of the correctional

institution.

USES AND DISCLOSURES THAT REQUIRE DHS TO PROVIDE YOU AN OPPORTUNITY TO OBJECT

AND OPT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, DHS may disclose to a

member of your family, a relative, a close friend or any other person you identify, your Protected Health

Information that directly relates to that person’s involvement in your health care. If you are unable to agree or

object to such a disclosure, DHS may disclose such information as necessary if it is determined that it is in

your best interest based on the professional judgment of DHS.

Disaster Relief. DHS may disclose your Protected Health Information to disaster relief organizations that

seek your Protected Health Information to coordinate your care, or notify family and friends of your location or

condition in a disaster. DHS will provide you with an opportunity to agree or object to such a disclosure

whenever it is practical to do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with your written

authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Revised April 2019

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply

to DHS will be made only with your written authorization. If you do provide DHS an authorization, you may

revoke it at any time by submitting a written revocation to the above-referenced Privacy Officer. Upon receipt,

DHS will no longer disclose Protected Health Information under the authorization. However, disclosures

made in reliance upon your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding Health Information DHS has about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to

make decisions about your care or payment for your care. This includes medical and billing records, other

than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in

writing, to the above referenced HIPAA Privacy Officer. DHS has up to 30 days to make your Protected

Health Information available to you and DHS may charge you a reasonable fee for the costs of copying,

mailing or other supplies associated with your request. DHS may not charge you a fee if you need the

information for a claim for benefits under the Social Security Act or any other state of federal needs-based

benefit program. DHS may deny your request in certain limited circumstances. If DHS does deny your

request, you have the right to have the denial reviewed by a licensed healthcare professional who was not

directly involved in the denial of your request, and DHS will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is

maintained in an electronic format (known as an electronic medical record or an electronic health record), you

have the right to request that an electronic copy of your record be given to you or transmitted to another

individual or entity. DHS will make every effort to provide access to your Protected Health Information in the

form or format you request, if it is readily producible in such form or format. If the Protected Health

Information is not readily producible in the form or format you request, your record will be provided in either

our standard electronic format. If you do not want this form or format, a readable hard copy form will be

provided. DHS may charge you a reasonable, cost-based fee for the labor associated with transmitting the

electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured

Protected Health Information.

Right to Amend. If you feel that Health Information DHS has is incorrect or incomplete, you may request

DHS to amend the information. You have the right to request an amendment for as long as the information is

kept by or for our office. To request an amendment, you must make your request, in writing, to the above-

referenced HIPAA Privacy Officer.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures DHS

made of Health Information for purposes other than treatment, payment and health care operations or for

which you provided written authorization. To request an accounting of disclosures, you must make your

request, in writing, to the above-referenced HIPAA Privacy Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health

Information DHS uses or disclosed for treatment, payment, or health care operations. You also have the right

to request a limit on the Health Information DHS discloses to someone involved in your care or the payment

for your care, like a family member or friend. For example, you could ask that DHS not share information

about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your

request, in writing, to the above-referenced HIPAA Privacy Officer. DHS is not required to agree to your

request unless you are requesting DHS restrict the use and disclosure of your Protected Health Information to

a health plan for payment or health care operation purposes and such information you wish to restrict pertains

solely to a health care item or service for which you have paid “out-of-pocket” in full. If DHS agrees, we will

comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communications. You have the right to request that DHS communicate

with you about medical matters in a certain way or at a certain location. For example, you can ask that DHS

Revised April 2019

only contact you by mail or at work. To request confidential communications, you must make your request, in

writing, to the above-referenced HIPAA Privacy Officer. Your request must specify how or where you wish to

be contacted. DHS will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may request a

copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still

entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact the above-

referenced HIPAA Privacy Officer.

CHANGES TO THIS NOTICE:

DHS reserves the right to change this notice and make the new notice apply to Health Information already

obtained as well as any information received in the future. DHS will post a copy of the current notice at our

office. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS:

If you have any questions about this notice, please contact:

Georgia Department of Human Services

HIPAA Privacy Officer

2 Peachtree Street, NW Suite 29-210

Atlanta GA 30303-3142

HIPAADHS@dhs.ga.gov

If you believe your privacy rights have been violated, you may file a complaint, in writing, by contacting the

above-referenced HIPAA Privacy Officer. You will not be penalized for filing a complaint.

You may also file with the Secretary of the Department of Health and Human Services. For more information

on HIPAA privacy requirements, HIPAA electronic transactions and code sets regulations and the proposed

HIPAA security rules, please visit ACOG’s web site, www.acog.org, or call (202) 863-2584.

I have read, understand, and acknowledge receipt of the DHS HIPAA Notice of Privacy Practices.

__________________________ __________________________

Signature Date

__________________________

Print Name

2 Peachtree St. N.W., Atlanta, GA 30303 | dhs.ga.gov

Notice to applicant: Please submit signed HIPAA notice

with all other application material to your nearest DCSS

office. It is not necessary to mail the HIPAA notice

separately unless notified by a DCSS representative.

Revised April 2019

DIVISION OF CHILD SUPPORT SERVICES

Direct Deposit Authorization Form (For use with online applications only)

To have child support sent directly to your checking or savings account, please read, complete and print this form. Include a voided

check or savings account deposit slip with your form. Mail both the voided check or savings account deposit slip and this form to your

local Child Support Services office.

Section 1: AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF CHILD SUPPORT PAYMENTS

I authorize the Division of Child Support Services (DCSS) to deposit my child support payments directly into my checking account or savings account as

specified below. DCSS is also authorized to adjust any over/under deposit it has made to my checking account or savings account. I understand

the deposits/adjustments will be made electronically by ACH transactions and I must allow the Federal Reserve two workdays from the disbursement date to

have the funds available to my financial institution. I also understand the following: It is my responsibility to provide correct routing and account information

for ACH transmissions by attaching a voided check or financial institution printout to this authorization. DCSS does no pre-note to verify my information. I

will immediately notify DCSS if my banking information changes. I must submit a new authorization form to change my direct deposit. I can stop my direct

deposit by notifying the DCSS Hotline or local office. I must notify the DCSS local office of any changes to my address. I must include my name and case

number on all correspondence regarding direct deposit. The DCSS Hotline and web site provide the date the DCSS system disbursed my payment; I must

verify with my financial institution when the payment is posted to my account and funds are available for withdrawal.

By signing below I signify that I have read and agree to all of the conditions listed above.

Signature:___________________________________________ Date Signed: _______________________

*****PLEASE TYPE OR LEGIBLY PRINT ALL INFORMATION BELOW IN INK*****

Section 2: CUSTODIAL PARENT INFORMATION

Name: (As it appears on your GA DDS check)

GA DCSS Case Number (if applicable):

Social Security Number

Additional GA DCSS Case Numbers:

Mailing Address

City:

State:

Zip:

Day-time Telephone Number:

Email:

Section 3: FINANCIAL INSTITUTION INFORMATION

Name of financial institution:

Routing Number:

Account Number:

Account Type:

[ ] Checking [ ] Savings

City:

State:

Telephone:

Section 4: *****FOR DCSS USE ONLY*****

Date received: ___/___/___

Initials:

Date input: ___/___/___

Initials:

Date verified: ___/___/___

Initials:

Please verify all information. Then, mail this completed form along with a voided check or savings account deposit slip to

the local child Support Services office.

Check here if this is a “Bank-Card Only” account [_]

For your information: If you have access to the internet, you may view your case and obtain payment information on the Customer

Online Services website at https://services.georgia.gov/dhr/cspp/do/Logon. First time users are required to register to obtain a user

ID and password. Once your case has been registered, you may obtain your IRN by calling the Contact Center at 1-844-MYGADHS (1-

844-694-2347 Toll Free).

Revised April 2019

Georgia EPPICard Debit MasterCard

The Division of Child Support Services (DCSS) no longer mails child support payments in the form of paper

checks. If you did not submit a request to have your child support payments deposited into your checking or

savings account, a Debit MasterCard will be mailed to you via first class mail within 7 to 10 business days from

the date the first child support payment is posted to your case.

The Georgia EPPICard Debit MasterCard allows you to:

1. Make purchases at merchant locations where MasterCard Debit cards are accepted

2. Get cash back at merchant locations where MasterCard Debit cards are accepted

3. Make bank teller and ATM cash withdrawals at locations where MasterCard is accepted

4. Access your child support payments anywhere in the U.S. where MasterCard Debit cards are accepted

If you do not receive your EPPICard within 7 to 10 business days from the date your first child support payment is

posted to your case, please contact Georgia EPPICard Customer Service at 1-800-656-1347. Once you have

received and activated your EPPICard you will be able to receive payment alerts by creating an account on the

EPPICard website.

Your Georgia EPPICard will expire every 3 years and a new card will be mailed to you.

Please be sure to update your address with DCSS every time your address changes.

For your information: If you have access to the internet, you may view your case and obtain payment

information on the Customer Online Services website at https://services.georgia.gov/dhr/cspp/do/Logon.

First time users are required to register to obtain a user ID and password. Once your case has been registered,

you may obtain your IRN by calling the Contact Center at 1-844-MYGADHS (1-844-694-2347 Toll Free).