BEAR RIVER BAND of the ROHNERVILLE RANCHERIA
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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA
P.O. Box 669, Loleta, CA 95551
Phone (707) 733-1900 ext 1017
Fax (707) 733-1877
VERIFICATION CHECKLIST
We need the following verification and documentation in order to proceed with the processing of
your application for Child Support Services:
Verification of your Social Security Number (for example, a copy of your Social
Security card, pay stub)
Verification of your child(ren)’s Social Security Number
Birth Certificate for your child(ren) - (actual or copy of the birth certificate)
Verification of your address (rent receipt, utility bill, mail received by you at that
address)
Copies of any court orders (Divorce/Dissolution, Temporary Support, child support, etc.)
that have already been issued
If Family Violence is claimed, then we will need a copy of the police report, Restraining
Order or Order of Protection issued by a court, or statement from two individuals
attesting to the family violence.
Copies of any receipts, records or proof of child support that has already been paid to you
Verification of any income you receive (Social Security Award letter, Unemployment
Compensation Award Letter, pay stubs for past three (3) months or other similar proof)
Tribal Enrollment
Please contact me at (707) 733-1900 ext. 1017 if you have any questions.
Thank you,
Tribal Case Specialist
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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA
P.O. Box 669, Loleta, CA 95551
Phone (707) 733-1900 ext 1017
Fax (707) 733-1877
Enclosed in an Application for Child Support Services, a Statement of Understanding and a
Tribal CSE pamphlet. The Application looks like we are requesting a lot of information but we
cannot start to help you and your child(ren) without a completed application and the information
requested.
The Tribal CSE pamphlet explains that the Bear River Band Child Support Services does not
take sides or represent either the custodial or non-custodial parent. We work for what is in the
best interest of the child(ren). We service the best interest of the child(ren) by working to locate
the non-custodial parent, taking necessary steps to determine paternity when necessary,
establishing and/or modifying a legitimate child support order, and attempting to collect child
support payments.
A Statement of Understanding is included with the Application. Please read and review it
carefully. By signing the Statement, you are agreeing to cooperate with the Bear River Band
Child Support program, Bear River Band tribal law, and applicable federal child support rules
and regulations.
Please refer to the enclosed Verification Checklist which indicates the proof and documentation
that you need to provide along with the application. Your application will be reviewed to
determine the best possible way to service your child(ren). Make sure to include any additional
information with your application that would help us provide services to your children.
Please contact Bear River Band Child Support Services should you have any questions regarding
the Statement of Understanding.
Please mail or return your completed application to:
Bear River Band Child Support Services
P.O. BOX 669
LOLETA, CA 95551
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BEAR RIVER BAND of the ROHNERVILLE RANCHERIA
P.O. Box 669, Loleta, CA 95551
Phone (707) 733-1900 ext 1017
Fax (707) 733-1877
APPLICATION FOR CHILD SUPPORT SERVICES
OFFICE USE ONLY:
Date Requested:
_____ Date received:
____ FGN:
____
Please mark all that apply:
This is my first application with the Bear River Band.
I am or the child(ren) are receiving assistance from the State of California.
I am or the child(ren) are receiving assistance from the_____________Tribal TANF Agency.
I am reopening my case with the Bear River Band.
I.
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:
Race:
If Native American, what tribe?
What is the relationship of the child(ren) to the custodial parent?
Male
Female
Who has legal custody?
Mailing Address:
City
State
Zip Code
Physical Address:
City
State
Zip Code
County of Residence:
Home Phone Number:
DOMESTIC VIOLENCE INFORMATION
Have you or your child(ren) of this application experience any type of abuse from the non-custodial parent?
Yes
No
Type:
Physical
Verbal
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?
No
Yes
If yes, do you want a Family Violence Non-Disclosure Statement to complete and return to this office?
Yes
No
If you decide not to fill out the statement at this time, you may request one at a later date.
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
LIST BELOW ALL PRESENT AND PAST EMPLOYMENT, beginning with the most recent and working back.
You should list all full-time, part-time work, military service, self-employment, other paid work, student and all
periods of unemployment. The entire five-year period must be accounted for without breaks.
Address
(City/State)
Name of Employer and Phone Number
From
Mo/Yr
To
Mo/Yr
Occupation
Hours per
week
Hourly
Wages
OTHER SOURCES OF INCOME: Please list income that you receive from anywhere else. Provide the source of the income, how
frequently you receive the income and the amount you receive. For Example: Social Security Disability, Supplemental Security
Income (SSI), Unemployment Compensation, Workman’s Compensation, Retirement, etc.
SOURCE OF INCOME
II.
FREQUENCY RECEIVED
AMOUNT RECEIVED
NON-CUSTODIAL PARENT INFORMATION: This section is about the person who DOES NOT have custody
of the children.
A. INFORMATION ABOUT PARENT 1, if not the custodial parent.
Full legal name:
Last
First
Maiden/alias name
Middle
Date of birth:
Place of birth (city, state):
Race:
If Native American, what tribe?
Height:
Eye color:
Social Security number:
Hair color:
Is parent 1 disabled?
Yes
No
Identifying marks (tattoos, scars, etc.):
Home address:
City
State
Zip Code
Cell phone/other number:
Home phone number:
Cell
Other
Is parent 1 currently residing with other parties?
Yes
No
If yes, with whom?
Relationship
Has parent 1 ever been in jail or prison?
If yes, when?
Where? (city, state)
Yes
No
List information about parent 1’s vehicle:
Year:
Make:
Model:
Color:
Tag Number:
State:
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
Military Service information:
Is parent 1 in the military?
Yes
Branch of service (check):
Air Force
No
If yes, dates of service:
Army
Marines
Reserve information: Is parent 1 enlisted in the reserve?
Navy
Yes
Coast Guard
National Guard
No
Please provide additional information about parent 1’s parents/relatives/friends:
Mother’s name:
Last
First
Middle
Address:
Father’s name:
Phone number:
City
Last
First
Middle
Address:
Relatives/Friend’s name:
State
Phone number:
City
Last
First
Address:
Zip Code
State
Zip Code
Phone number:
Middle
City
State
Zip Code
LIST BELOW ANY EMPLOYMENT, for parent 1 beginning with the most recent.
Address
(City/State)
Name of Employer
and Phone Number
From
Mo/Yr
To
Mo/Yyr
Occupation
Hours per
Week
Hourly
Wages
B. INFORMATION ABOUT PARENT 2, if not the custodial parent.
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:
Is parent 2 disabled?
Yes
No
Identifying marks (tattoos, scars, etc.):
Home address:
Home phone number:
Is parent 2 currently residing with other parties?
Yes
No
Has parent 2 ever been in jail or prison?
Yes
No
City
State
Cell phone/other number:
Zip Code
Cell
Other
If yes, with whom?
Relationship
If yes, when?
Where? (city, state)
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
List information about parent 2’s vehicle:
Year:
Make:
Model:
Color:
Tag Number:
State:
Military Service Information:
Is parent 2 in the military?
Yes
Branch of service (check):
Air Force
No
If yes, dates of service:
Army
Marines
Reserve information: Is parent 2 enlisted in the reserve?
Navy
Yes
Coast Guard
National Guard
No
Please provide additional information about parent 2’s parents/relatives/friends:
Mother’s name:
Last
First
Middle
Address:
Phone number:
City
Father’s name:
Last
First
State
Middle
Address:
Phone number:
City
Relatives/Friend’s name:
Last
First
State
Zip Code
Phone number:
Middle
Address:
Zip Code
City
State
Zip Code
LIST BELOW ANY EMPLOYMENT, for parent 2 beginning with the most recent.
Name of Employer
and Phone Number
III.
Address (City/State)
From
Mo/Yr
To
Mo/Yr
Occupation
Hours per
week
Hourly
Wages
INFORMATION ABOUT THE CHILD(REN). Please list only children with the same parentage.
CHILD #1
Is the child receiving TANF, Medicaid and/or medical benefits?
Full legal name of child: Last
Date of birth:
City of birth:
Sex:
Race:
Does this child live with you?
Yes
No
School address:
First
Yes
No
If yes, where:__________________
Middle
Social Security number:
State of birth:
If Native American, what tribe?
If the child is 18, is he/she currently in
high school?
Yes
No
City
State
Zip Code
Could either parent name anyone else with possible parentage?
Yes
No
If yes, who?
Has enrollment card been issued?
Yes
No
Name of school:
Graduation Year:
Last name
First name
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
CHILD #2
Is the child receiving TANF, Medicaid and/or medical benefits?
Full legal name of child: Last
First
Date of birth:
City of birth:
Sex:
Race:
Yes
No
If yes, where:__________________
Middle
Social Security number:
State of birth:
If Native American, what tribe?
If the child is 18, is he/she currently in
high school?
Yes
No
City
State
Zip Code
Does this child live with you?
Yes
No
School address:
Could either parent name anyone else with possible parentage?
Yes
No
If yes, who?
Has enrollment card been issued?
Yes
No
Name of school:
Graduation Year:
Last name
First name
CHILD #3
Is the child receiving TANF, Medicaid and/or medical benefits?
Full legal name of child: Last
First
Date of birth:
City of birth:
Sex:
Race:
Yes
No
If yes, where:__________________
Middle
Social Security number:
State of birth:
If Native American, what tribe?
Does this child live with you?
Yes
No
School address:
If the child is 18, is he/she currently in
high school?
Yes
No
City
State
Zip Code
Could either parent name anyone else with possible parentage?
Yes
No
If yes, who?
Has enrollment card been issued?
Yes
No
Name of school:
Graduation Year:
Last name
First name
CHILD #4
Is the child receiving TANF, Medicaid and/or medical benefits?
Full legal name of child: Last
First
Date of birth:
City of birth:
Sex:
Race:
No
If yes, where:__________________
Middle
Social Security number:
State of birth:
If Native American, what tribe?
Does this child live with you?
Yes
No
School address:
If the child is 18, is he/she currently in
high school?
Yes
No
City
State
Zip Code
Could either parent name anyone else with possible parentage?
Yes
No
IV.
Yes
If yes, who?
Has enrollment card been issued?
Yes
No
Name of school:
Graduation Year:
Last name
First name
INFORMATION ABOUT CHILD SUPPORT OBLIGATION.
The relationship between the parents of the child(ren): (check)
Never married
Married/living apart
Divorced
Lived together
Date of separation:
Date of living apart:
Date of marriage:
City:
County:
Date of Decree of Divorce:
State:
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
Have you ever appeared in any court, regarding the above child(ren), for one of the following reasons? (check)
Child Support
Divorce
Child Custody
Legal paternity
Domestic Violence
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.
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 child support was ordered, how much?
If tribal/CFR court, what tribe issued the order?
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 that affects the child(ren)?
Date child(ren) placed in ICW/DHS custody:
Child(ren) in Indian Child Welfare (ICW) or DHS custody?
If child(ren) in ICW/DHS care, what tribe or county?
Date of filing:
Court case number:
County:
State:
In what court is the paperwork filed?
If tribal court, what
tribe?
How often?
If child support has been ordered, how much is the non-custodial parent ordered to pay?
If a private attorney was consulted for this order, please give name:
Attorney’s address/phone number
V.
REFERRAL SECTION
Were you referred to Bear River Band Child Support Services by another agency or department?
If yes, by whom? ________________________________________________________
VI.
No
Please indicate how you would like to receive your child support payments:
Check
VII.
Yes
Direct Deposit or
Debit card
COMMENTS: Please provide additional information that your feel could assist our office in enforcing your child support order.
(If necessary, you may use the back of the page.)
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BEAR RIVER BAND CHILD SUPPORT APPLICATION
STATEMENT OF UNDERSTANDING
1.
I understand that BRBCSS attorneys or child support staff do not represent me.
2.
I agree to fill out forms and affidavits as requested, to have genetic testing and attend court to give testimony if
required. I agree to cooperate fully with BRBCSS, law enforcement offices and the court. I will notify BRBCSS of
my new address in writing every time I move.
3.
I agree to give all identifying information requested to assist in locating and collecting child support from the noncustodial 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.
4.
I understand that BRBCSS cannot help with issues such as custody and property settlements. I agree to tell BRBCSS
if I hire a private attorney to collect or modify child support or spousal support for me.
5.
I agree that starting with the date of my application all money paid for child support will go through the Bear River
Band Child Support Payment Center. I give BRBCSS the authority to endorse child support checks made out to me
6.
I understand if I keep child 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, BRBCSS will recover the overpayment
from me
7.
I understand and agree to all the terms above. I understand that if I violate any of the agreements or fail to cooperate
with BRBCSS, my case may be closed. The information provided in this application is true and correct to the best
of my knowledge.
Date:
Signature:
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This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.