Application for Child Support Services
Your Information
Child Information
Court Order Information
Court Order Information
Court Order Summary
Health Coverage Information
Health Coverage Information
Application Summary
Application Summary
Confirmation
Additional Information About Child
Child Name:
Note: an asterisk [
*
] indicates a required field.
Was the biological mother married at the time she became pregnant or gave birth?
Yes
No
Unknown
Is the father's name on the birth certificate?
Yes
No
Unknown
Whose name is listed on the child's birth certificate as the father?
Has the father been determined by legal action?
Yes
No
Does the child live in the State of Nebraska as a result of the acts or directives of the Non-custodial Parent?
Yes
No
Has the Non-custodial Parent lived with the child in the State of Nebraska?
Yes
No
Was the child conceived in Nebraska?
Yes
No
Unknown
Has Non-custodial Parent given you support for prenatal expenses, the care of the child or brought the child gifts?
Yes
No
Does this child have any extraordinary medical problems?
Yes
No
Is this child the subject of pending juvenile court case?
Yes
No
Has this child ever received Aid to Dependent Children (ADC) / Temporary Assistance for Needy Families (TANF) assistance in the past?
Yes
No
Unknown
Please provide State(s) and Date(s).
Has the child ever received Foster Care Services in the past?
Yes
No
Unknown
Please provide State(s) and Date(s).
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