# BEAR RIVER BAND of the ROHNERVILLE RANCHERIA > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Abear_river%3Ae9b6141ad100d18f ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text 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 CSS-0203 | 1 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 CSS-0200(a) | 1 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. CSS-0200 | 1 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: CSS-0200 | 2 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) CSS-0200 | 3 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 CSS-0200 | 4 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: CSS-0200 | 5 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.) CSS-0200 | 6 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: CSS-0200 | 7 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Abear_river%3Ae9b6141ad100d18f. Public record. Not legal advice.