Child Support Referral Fillable PDF

Please know that incomplete referrals and assignments will delay the processing time for a determination of eligibility. Information is required on the custodial parent(s), non-custodial parent(s) and children.

If children do not have the same mother and father, a separate referral must be completed.

If you have questions or need assistance in completing the Child Support Referral, please ask.

The Quinault Indian Nation Child Support Program will use your Social Security Number for child support enforcement purposes as defined in Title IV-D of the Social Security Act.

Mother's Information, if Not Custodian

Is the mother deceased?

Yes

Has the mother been deported?

Yes

Name

First Middle Last

Alternate Name(s)

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Race

Height

Weight

Hair Color

Eye Color

Native Language

Identifying Marks

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Employer’s Address

Street Address City State / Province / Region ZIP / Postal Code

Income

Income Received

Per Hour

Per Month

Has a second job?

Yes

If yes, where

Ever been in jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Mother’s Parents

If deceased, leave blank.

First Middle Last

Address

If deceased, leave blank.

Street Address City State ZIP Code

Phone Number

If deceased, leave blank.

Message Number

If deceased, leave blank.

Father's Information, if Not Custodian

Is the father deceased?

Yes

Has the father been deported?

Yes

Name

First Middle Last

Alternate Name(s)

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Race

Height

Weight

Hair Color

Eye Color

Native Language

Identifying Marks

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Employer’s Address

Street Address City State ZIP Code

Income

Income Received

Per Hour

Per Month

Has a second job?

Yes

If yes, where

Ever been in jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Father’s Parents

If deceased, leave blank.

First Middle Last

Address

If deceased, leave blank.

Street Address City State ZIP Code

Phone Number

If deceased, leave blank.

Message Number

If deceased, leave blank.

Head of Household Information

Head of Household Name(Required)

First Middle Last

Alternate Name(s)

Social Security #(Required)

Date of Birth

Gender

Female

Male

Physical Address

Street Address City State ZIP Code

Mailing Address(Required)

Street Address City State ZIP Code

Race(Required)

Enrolled member of a federally recognized Indian tribe?(Required)

Yes

If yes, name of tribe

Relationship to Child(Required)

Do you have legal custody?(Required)

Yes

If no, who has legal custody

Is private attorney currently working on your child support case?

Yes

If yes, name and phone number of attorney

Domestic Violence Information

Have you or the child/ren in the household ever experienced any type of abuse?(Required)

Yes

Have you ever had a protective order against you or the non-custodial parent?(Required)

Yes

If yes, what court issued the order?

Do you believe that you or the child/ren may be at risk of emotional and/or physical harm if the non-custodial parent knows where to find you?(Required)

Yes

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

Yes

Child Information 1

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name(Required)

First Middle Last

Social Security #(Required)

Date of Birth(Required)

Place of Birth City, County, State, Country(Required)

Gender(Required)

Female

Male

Race(Required)

Enrolled member of a federally recognized Indian tribe?(Required)

Yes

If yes, name of tribe

Enrollment Number

Legal Status(Required)

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 2

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 3

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Information 4

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Enrollment Number

Legal Status

A support order has been issued for this child

Paternity has been established for this child, but no order has been issued

Paternity for this child needs to be established

Parent are living apart and there is no support order

Child Support Obligation

What is the relationship between the mother and father of the child/ren?

Never Married

Married/Living Together

Married but Separated

Divorced

If separated, date of separation

If divorced, date of divorce

Have you ever appeared in court for any of the following reasons?

Check All that Apply

Child Support

Child Custody

Legal Paternity

Divorced

Domestic Violence

Court Orders

Date of Order

Court Case Number

What court issued the order?

City

County

State

If Tribal Court, which Tribe?

Was child support ordered?

Yes

If Yes, how much ordered to pay child support

If Yes, how often ordered to pay child support

Every Week

Every Two Weeks

Every Month

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

Pending Court Orders

Are there any legal action(s) that may affect the child/ren?

Yes

Is the child/ren in Indian Child Welfare (ICW) or Child Welfare custody?

If yes, complete the following information.

Yes

Date child/ren were placed in ICW/CW custody

If child/ren are in ICW care, with what Tribe?

Date Filed

Court Case Number

City

County

State

What court was the paperwork filed at?

If Tribal Court, which Tribe?

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

Modification of Child Support

Date of Order

Court Case Number

What court issued the order?

City

County

State

If Tribal Court, which Tribe?

Were modifications made to the Child Support Order?

Yes

If modified, indicate how much

If modified, indicate how often

Every Week

Every Two Weeks

Every Month

Was a private attorney consulted on this case?

Yes

If yes, name and phone number of attorney

The completed PDF form will be emailed to you please provide an email address below.

Email(Required)