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Agreement, Consent and Limited Power of Attorney

When you accept a Tribal TANF cash grant, you are assigning your child support and medical support rights to the Tribal Indian Nation. When you agree to assign your support rights, you are agreeing that the Quinault Indian Nation may keep your support payments to repay the Quinault Indian Nation and the federal government for assistance that is paid to your family.

When you accept a Tribal TANF cash grant, you are agreeing to cooperate with the Tribal Indian Nation and the Washington State Division of Child Support by:
1. Helping to establish paternity, if applicable.
2. Helping to establish or modify your support order.
3. Sending all support payments that you directly receive from the non-custodial parent to:

4. Appointing DCS and/or the Tribal Indian Nation to accept and endorse all child support, spousal support and medial support payments.
5. Informing Tribal TANF in writing when you no longer want child support enforcement services. When you stop receiving a Tribal TANF cash grant, child support will continue to be enforced unless you request that services be stopped.

Head of Household Name(Required)
Child Name(Required)
Child Name
Child Name
Child Name

Please Read This form in Its Entirety Before Signing It

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