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DHS-1201 (Rev. 2-24) Previous edition obsolete. 1 DHS-1201, IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL Michigan Department of Health and Human Services Office of Child Support (OCS) (Revised 2-24) FOR OFFICE USE ONLY Date Requested Date Provided Date Filed Program 748 Provided IV-D Case Number Case Number County District Unit Worker Check your relationship to the child(ren) for whom you are applying for child support services: Custodial Parent – Complete all sections of the form, enter information about you in Section A. Non-Custodial Parent or Alleged Father – Complete all sections of the form except Section F, enter information about you in Section B. Other Caretaker, Specify Complete all sections of the form, enter information about you in Section A. Complete information about each parent who is not in the home in Section B. (Complete a separate application for each parent who is not in the home.) SECTION A – INFORMATION ABOUT THE CUSTODIAL PARENT/CARETAKER OF THE CHILD 1. Name (First, Middle, Last, Suffix) Maiden Name (if applicable) 2. Date of Birth 3. Social Security Number 4. Home Address (PO Box No., No. and Street) City State Zip Code County 5. Home Phone Number 6. Work Phone Number 7. Cell Phone Number 8. Email Address 9. Race (Select one) Black/African American East/Southeast Asian (Chinese, Japanese, Korean) Indigenous (Native People, Native Alaskan) Middle Eastern, North African, Arab (Iranian, Syrian, West Asian) Native Hawaiian, Pacific Islander White (German, Irish, English) South Asian (East Indian, Pakistani, Bangladeshi) Multi-Racial Other Prefer not to answer/unknown ---PAGE BREAK--- DHS-1201 (Rev. 2-24) Previous edition obsolete. 2 10. Ethnicity (Select one) Hispanic, Latino, Spanish origin Not of Hispanic, Latino, Spanish origin Prefer not to answer/unknown SECTION B – INFORMATION ABOUT THE PARENT WHO IS NOT IN THE HOME 11. Parent’s Name (First, Middle, Last, Suffix) Maiden Name (if applicable) 12. Social Security Number 13. Date of Birth 14. Age 15. Sex Male Female 16. Home Address (PO Box No., No. and Street) Current Last Known City State Zip Code 17. Home Phone Number 18. Cell Phone Number 19. Weight 20. Height 21. Hair Color 22. Eye Color 23. Email Address 24. (City, State) 25. Driver’s License Number 26. Vehicle Year, Make, Model 27. License Plate Number 28. Race (Select one) Black/African American East/Southeast Asian (Chinese, Japanese, Korean) Indigenous (Native People, Native Alaskan) Middle Eastern, North African, Arab (Iranian, Syrian, West Asian) Native Hawaiian, Pacific Islander White (German, Irish, English) South Asian (East Indian, Pakistani, Bangladeshi) Multi-Racial Other 29. Ethnicity (Select one) Hispanic, Latino, Spanish origin Not of Hispanic, Latino, Spanish origin 30. Identifying Marks (Scars, Tattoos, etc.) 31. Tribe Name 32. Is there a tribal support order? Yes No 33. First Employer Name Current Last Known 34. Employer Address (PO Box No., No. and Street) City State Zip Code 35. Phone Number 36. Second Employer Name Current Last Known ---PAGE BREAK--- DHS-1201 (Rev. 2-24) Previous edition obsolete. 3 37. Employer Address (PO Box No., No. and Street) City State Zip Code 38. Phone Number SECTION C – MARITAL STATUS INFORMATION 39a. Has the mother ever married? No Yes (If yes, answer b, c, d) b. Name of Spouse c. Date Married d. Place (City, County, State) 40a. Is the mother Separated Legally Separated (Answer b, c) b. Date c. Court Order Exist? No Yes (If yes, answer d, e) d. Court Order Number e. Where (City, County, State) 41a. Is the mother Divorced Divorce filed (Answer b, c) b. Date c. Court Order Exist? No Yes (If yes, answer d, e) d. Court Order Number e. Where (City, County, State) Attach a copy of all court orders pertaining to the family members listed on this application, including Personal Protection Orders and guardianship papers. SECTION D – INFORMATION ABOUT CHILD(REN) Child One (Include separate pages if more than three children) 42a. Child’s Full Name (First, Middle, Last, Suffix) b. Date of Birth c. Social Security Number d. Sex Male Female e. City, County and State of Birth f. Who paid for the birth of child? Medicaid Private Insurance Mother Father Other g. When and where did the mother become pregnant? Date City County State h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No If yes, provide the following information about that document: Date City County State Child’s Health Care Coverage Information (attach copy of card(s), front and back) 43a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type PPO PPOM Traditional d. Policy or Group Number ---PAGE BREAK--- DHS-1201 (Rev. 2-24) Previous edition obsolete. 4 Child Two 44a. Child’s Full Name (First, Middle, Last, Suffix) b. Date of Birth c. Social Security Number d. Sex Male Female e. City, County and State of Birth f. Who paid for the birth of child? Medicaid Private Insurance Mother Father Other g. When and where did the mother become pregnant? Date City County State h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No If yes, provide the following information about that document: Date City County State Child’s Health Care Coverage Information (attach copy of card(s), front and back) 45a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type PPO PPOM Traditional d. Policy or Group Number Child Three 46a. Child’s Full Name (First, Middle, Last, Suffix) b. Date of Birth c. Social Security Number d. Sex Male Female e. City, County and State of Birth f. Who paid for the birth of child? Medicaid Private Insurance Mother Father Other g. When and where did the mother become pregnant? Date City County State h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? Yes No If yes, provide the following information about that document: Date City County State Child’s Health Care Coverage Information (attach copy of card(s), front and back) 47a. Policy Holder’s Name b. Health Care Company Name (Non-Medicaid) c. Coverage Type PPO PPOM Traditional d. Policy or Group Number ---PAGE BREAK--- DHS-1201 (Rev. 2-24) Previous edition obsolete. 5 SECTION E – GENERAL INFORMATION 48. I believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or the child. Yes No 49. I have received or I am currently receiving benefits from the Family Independence Program (FIP) or I have received past benefits from Aid to Dependent Children (ADC). Yes No If yes, when? Where? 50. I have received or I am currently receiving Medicaid (MA). Yes No If yes, when? Where? 51. I am currently receiving Food Assistance Program (FAP). Yes No I am currently receiving Child Development and Care (CDC). Yes No SECTION F – ACKNOWLEDGEMENT FOR CUSTODIAL PARENTS AND CARETAKERS The Michigan Office of Child Support (OCS) processes child support payments through the Michigan State Disbursement Unit (MiSDU), which is part of the Michigan Department of Health and Human Services The MiSDU receipts and distributes payments by direct deposit to a bank account, to a debit card, or by paper check. If I am sent money in error or overpaid, the MiSDU will take all the necessary steps to correct errors in the processing of my child support payments. By checking the “yes” box below, I give OCS permission to withhold an incremental amount specified below from future child support payments owed to me. To revoke my consent, I must notify the Friend of the Court office. Failure to check “yes” has no effect on my eligibility for IV-D Child Support services through OCS. Yes (check one) 10% 25% or 50% Failure to choose a percentage will result in a default amount of 25%. No, contact me before you attempt to recover an amount from my support payments SECTION G – ACKNOWLEDGEMENT FOR ALL APPLICANTS I request child support services available under Title IV-D of the Social Security Act. All Services Locate Only (for custodial parents and caretakers only) Medical Support Only (for Medicaid cases only) I understand that disclosure of my Social Security number is mandated by the Social Security Act, 42 USC 666(a)(13), in order that Michigan’s child support program may provide services related to the establishment of paternity and the establishment, modification and enforcement of child support obligations. I understand that I must cooperate in taking support action to ensure that my child support case remains open. I declare that the information provided above is true and correct to the best of my knowledge and agree to report changes in my circumstances that may affect support action in my case. ---PAGE BREAK--- DHS-1201 (Rev. 2-24) Previous edition obsolete. 6 I certify that I have received a copy of DHS Publication 748, “Understanding Child Support, A Handbook for Parents.” Applicant’s Signature (Signature is Required) Date Applicant’s Printed Name Return completed application to: Michigan Department of Health and Human Services Office of Child Support PO Box 30744 Lansing, MI 48909 The Michigan Department of Health and Human Services does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy. This institution is an equal opportunity provider.