Modoc Tribe of Oklahoma

Modoc Tribe of Oklahoma

Tribal Child Support Services

Where Children Come First

The following pages include an explanation of services provided by the Modoc Tribe Child Support Services an

application and a reminder sheet of items you must submit with your completed application. It looks like a lot of

information, but everything in this packet is important. Without a complete application, we cannot start to help

you and your child or children.

The first thing you should know about the Modoc Tribe Child Support Services is we do not take sides. We work

for what is in the best interest of your child or children. We do that by working to locate a non-custodial parent,

taking necessary steps to determine paternity, establish and/or modify a legitimate child support order, and attempting to collect child support payments.

Please provide copies of your children’s state birth certificate, CDIB card, Social Security card, two most

recent payroll stubs, divorce decree and all orders signed by the court and a copy of the paternity affidavit if

you have one. Once your application is complete and we have all the required forms, it will be reviewed to determine the best possible way to help your child or children. Again, we cannot begin working on your case until we

have all the required documentation. Should you have additional information that would help us provide services

to your children, please include the information with your application.

Please read the Statement of Understanding carefully. By signing the Statement, you agree to cooperate with the

Modoc Tribe Office of Child Support Services program, Modoc tribal law and applicable federal child support rules

and regulations. If you have any questions, contact a Modoc Tribe Child Support employee at 918-540-1501 or

1-888-540-1501 before you sign the document. Once the application is complete please mail to Tribal Child Support Services, PO Box 1110, Miami, OK 74355, or PO Box 1727, Seminole, OK 74818.

STATEMENT OF UNDERSTANDING:

1,

10.

li.

I understand the Modoc Tribe Child Support Services (MTCSS) is here to act in the public interest to protect children’s rights,

protect the taxpayers, the tribe, and to make sure that the parents financially support their children. I understand that the responsibilities of the child support program do not allow the staff of MTCSS to have the same confidential relationship with me as I

would have with a private attorney. Information I provide will be kept from the general public but may be used as needed to collect

support from either parent. I give MTCSS permission to give any necessary information to law enforcement officers, public

officials, court or others to assist me to collect child support or medical support.

. [understand that MTCSS attorneys or child support staff does not represent me.

. Lagree to fill out forms and affidavits as requested, to have genetic testing and attend court to give testimony. I agree to cooperate

fully with MTCSS, law enforcement offices and the court. I will notify MTCSS of my new address in writing every time I move.

Tagree to give all identifying information requested to assist in locating and collecting child support from the non-custodial parent

(NCP) and/or prove who is the biological father of my child(ren), This includes any information that I know about or any

documentation that I have.

. Tunderstand that MTCSS cannot guarantee that it can determine who the biological father of my child is, collect the money from

the NCP, enforce a court order for support or obtain a support order from the court. I understand that MTCSS cannot help with

issues such as custody and property settlements. | agree to tell MTCSS if] hire a private attorney to collect or modify child support

or spousal support for me.

. agree MTCSS will decide on the best way to collect the child support. This will include taking the overdue support from federal

and state tax refunds that are due to the NCP. I understand that money collected from federal or state tax intercept will be applied

to monies owed to the tribe or state first for funds expended on behalf of my children and myself. I understand that tax intercepts

may take refunds due to both the NCP and current spouse on joint returns. I understand that MTCSS or a state agency will hold

the intercept for up to six months. I understand that I may receive tax collections that are actually owed to the NCP’s current

spouse and I agree that if the NCP’s current spouse files an Injured Spouse claim for his/her portion of the tax refund collection,

I will return that portion to MTCSS.

[agree that starting with the date of my application all money paid for child support will go through the Child Support Services

Tribal Payment Center. I give MTCSS the authority to endorse child support checks made out to me. I understand that if I do not

notify MTCSS of direct payments or turn in child support paid directly to me, my case will be closed.

. Iunderstand if] keep child support payments to which I am not entitled because the NCP paid me directly for support assigned to

the tribe or state or because payments were sent to me in error, MTCSS will recover the overpayment from me. I understand

MICSS shall be entitled to recover the overpayment by withholding amounts from my child support payments and/or through

interception of my state tax refund.

L understand it is law that MTCSS will collect money owed to the tribe or state for any TANF/AFDC my children received in the

past or is/are currently receiving. Any amount of money collected that is more than what is due every month for current support

will be paid to the tribe or state for any TANF/AFDC paid to me or my children in the past.

Tunderstand and agree to all the terms above. I understand that if] violate any of the agreements or fail to cooperate with MTCSS,

my case will be closed. The information provided in this application is true and correct to the best of my knowledge.

I understand that the MTCSS has an agreement with the state of Oklahoma to submit my case for tax offset and other enforcement

activities as needed to provide the full support for my children. I further understand that the State of Oklahoma will open my case

for limited services only.

Initial Date

go Se, MODOC TRIBE OF OKLAHOMA

OFFICE OF CHILD SUPPORT

Services APPLICATION FOR CHILD SUPPORT SERVICES

FOFFICE USE ONLY

| Date Requested: cae ee Date Received: 2 : RGN:

PLEASE PRINT WITH BLUE OR BLACK INK

Please mark all that apply:

C1 This is my first application with the Modoc Tribe of Oklahoma.

C1 Lam or the child(ren) are receiving assistance from the State of Oklahoma.

LC 1am reopening my case with the Modoc Tribe of Oklahoma.

C1 tam requesting service on both parents (If CP is not mom or dad)

|. CUSTODIAL PARENT: This section is about the person with whom the child(ren) actually lives.

Full legal name: Last First Middle Maiden/alias name

Date of birth: Social Security Number: sex: ClMale DFemale

Race: If Native American, what tribe?

What is the relationship of the child(ren) to the custodial parent? Who has legal custody?

Mailing address: City State Zip code

Email address: Receive correspondence by email? [Yes [JNo

County of residence: Home phone number:

DOMESTIC VIOLENCE INFORMATION

Have you or the child(ren) of this application experience any type of abuse from the non-custodial parent?

ClYes [JNo Type: [] Physical [_] Verbal [1] Sexual

Has the non-custodial parent had a protective order against him/her? _[] Yes [] NO

If yes, what court issued the order? Date

Do you believe that you or the child(ren) may be at risk of emotional or physical harm if the other parent knows where to find you? (] Yes [J NO

If yes, do you want a Family Violence Non-Disclosure Statement to complete and return to this office?

L}Yes [J] No __ Ifyou decide not to fill out the statement at this time, you may request one at a later date.

I. NON-CUSTODIAL PARENT INFORMATION: This section is about the person who DOES NOT have custody of the children.

A. INFORMAITON ABOUT THE FATHER or the person who may be the father of the child(ren), if not the custodial parent.

Full legal name: Last First Middle Alias name

Date of birth: Place of birth (city,state): Social Security Number:

Race: If Native American, what tribe?

Height: Eye color: Hair color:

Identifying marks (tattoos, scars, etc.) Is the father disabled?

Yes _[LINo

Home address: City State Zip code

Home phone number. Cell phone/pager number: Cal Pager

Email address:

Has father ever been in jail or prison? If yes, when? Where? (city,state)

OlYes (JNo

INFORMATION ABOUT FATHER CONTINUED

Military service information:

Is the father in the military?L] Yes [_] No

If yes, dates of service:

Branch of service (check) LJAir Force LJArmy L]Marines LINavy LlCoast Guard [National Guard

LIST BELOW ANY EMPLOYMENT, for the father beginning with the most recent.

Name of Company and Phone Number Address (city/state) From mo/yr

To mo/yr Occupation |Hours per week] Hourly income

B. INFORMAITON ABOUT THE MOTHER,

if not the custodial parent.

Lives (CIJNo

Full legal name: Last First Middle Maiden/alias name

Date of birth: Place of birth (city,state): Social Security Number:

Race: If Native American, what tribe?

Height: Eye color: Hair color:

Identifying marks (tattoos, scars, etc.) Is the mother disabled?

Lives [J No

Home address: City State Zip code

Home phone number: Cell phone/pager number: Cell Pager

Is the mother currently residing with other parties? lf yes, with whom? Relationship

Has mother ever been in jail or prison?

LlYes [INo

lf yes, when?

Where? (city,state}

Military service information:

Is the mother in the military? ] Yes [_] No

If yes, dates of service:

Branch of service (check) [_]Air Force [JArmy [1Marines L]Navy []Coast Guard C] National Guard

LIST BELOW ANY EMPLOYMENT, for the mother beginning with the most recent.

Name of Company and Phone Number Address (city/state} From mofyr

To mo/yr Occupation [Hours per week| Hourly income

lit, INFORMATION ABOUT THE CHILD(REN). Please list only children with the same mother and father.

Is this child receiving TANF, Medicaid and/or medical benefits? ([JYes [No If yes, where:

Full legal name of child: Last First Middle Social Security Number:

Date of birth: City of birth: State of Birth:

Sex: Race: If Native American, what tribe? Has CDIB been issued?

ClYes [No

Does this child live with you?

if the child is 18, is he/she currently in

high school? []Yes []No

Name of school:

School address: City

State Zip code

Graduation year:

OlYes [No

Will the father name anyone else as a possible father? If yes, who?

Last name

First name

INFORMATION ABOUT THE CHILD(REN). Continued

Is this child receiving TANF, Medicaid and/or medical benefits? [Yes [] No If yes, where:

Full legal name of child: Last First Middle Social Security Number:

Date of birth: City of birth: State of Birth:

Sex: Race: If Native American, what tribe? Has CDIB been issued?

LlYes LINo

Does this child live with you?

{f the child is 18, is he/she currently in

Name of school:

high school? [JYes []No

School address: City State Zip code Graduation year:

Will the father name anyone else as a possible father? \f yes, who? Last name First name

ClYes [No

Is this child receiving TANF, Medicaid and/or medical benefits? []Yes [)No If yes, where:

Full legal name of child: Last First Middle Social Security Number:

Date of birth: City of birth: State of Birth:

Sex: Race: lf Native American, what tribe? Has CDIB been issued?

ClYes [LINo

Does this child live with you?

If the child is 18, is he/she currently in

Name of school:

DYes {(JNo

high school? []Yes [| No

School address: City State Zip code Graduation year:

Will the father name anyone else as a possible father? If yes, who? Last name First name

WV. INFORMATION ABOUT CHILD SUPPORT OBLIGATION.

The relationship between the mother and father of the child(ren): (check)

(Never married []Married/living apart [_] Divorced [Lived together

Date of separation:

Date of living apart:

Date of Decree of Divorce:

Date of Marriage:

City:

County: State:

Have you ever appeared in any court, regarding the above child(ren), for one of the following reasons? (check)

(Child support

If yes, where did you appear (city/county and state)?

Please complete portions A and B to the best of your knowledge. If you need assistance completing any of these portions you may call or

visit our office for assistance.

1 Diverce [Child custody

[]Legal paternity [] Domestic violence

A. COURT ORDER INFORMATION. (Attach copies of your divorce, decree, paternity order, custody order or any tribal orders, etc.)

Date of order:

Court case number:

What court?

City:

County:

State: If tribal or CFR court what tribe issued the order?

If child support was ordered, how much?

Per week, bi-weekly or per month?

If a private attorney was consulted for this order, please give name, address and phone number.

Name of attorney currently working on your case:

Attorney’s address/phone number:

B. PENDING COURT ORDERS. (please attach copy)

Is there any legal action pending in any other tribal/state court?

If so, what court?

VI. At the time our office is able to enforce a child support order, please indicate how you would like to receive your child support

payments.

Please select: (J Direct deposit or

CO Debit card

VIL AFFIDAVIT OF CHILD SUPPORT RECEIVED (directly paid to you). Use one form for payments RECEIVED from one parent.

1. If you have not received any child support payments from the non-custodial parent, please complete section A. Do not forget to

sign and date the Affidavit before a notary public.

2. If you have received child support from the non-custodial parent, complete section A and B. Start with the most recent year you

received child support or were given a judgment and work back. Do not forget to sign and date the Affidavit before a notary public.

Section A.

I , State the following to be records of any/all direct payments from

C1 Ihave not received any child support payments from the non-custodial parent.

CO Ihave recieved child support payments from the non-custodial parent. These payments were made directly to me, not through the

State of Oklahoma, or Tribal Payment Center, for the following children.

Child's Name Date of Birth

Section B. INCLUDE ONLY PAYMENTS RECEIVED FOR CHILD SUPPORT

*Indicate by an (x) any time children were not in your care for 30 days or more.

20 20 20 20 20 20 20

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Applican’t signature: Date:

STATE OF: (NOTARY USE ONLY)

COUNTY OF:

| verify that the above named person signed this affidavit before me on this day of , 20

Notary public:

My commission expires: Commission number:

Custodial Parent's Signature:

Date:

State of:

County of:

| verify that the above named person signed this affidavit before me on this day

of , 20

Notary Public Signature:

Commission number:

Commission expires on:

REFERRAL SECTION

How were you referred ta Modoc TCSS?

COMMENTS: Please provide additional information that you feel could assist our office in enforcing your child support order.