Mississippi MDHS-CSE-675 Revised 03-01-2020
Page 5 of 6
By signing this application, I understand that:
• I have assigned to MDHS any and all rights and interests in any cause of action past, present, or future that I or the child(ren) included in
this application may have against any parent failing to provide for the support of the minor child(ren);
• A non-refundable fee of $25 will be charged as an application fee and to recover the costs of any services performed for applicants who are
not receiving public assistance [Temporary Assistance for Needy Families, (TANF) or Supplemental Nutritional Assistance Program
(SNAP)]. No action will be taken until the application fee is paid;
• A non-refundable annual fee of $35 will be collected from distributed child support in excess of $550 for each October – September annual
period for applicants who are not currently receiving Supplemental Nutritional Assistance Program (SNAP) benefits and who have never
received Temporary Assistance for Needy Families (TANF) benefits. This amount will be collected from the next distributed payment or
payments until the fee is paid in full.
• There may be additional fees necessary, such as: court costs, filing fees, service of process fees;
• MDHS does not guarantee that efforts on my behalf will be successful;
• If I do not cooperate with MDHS, my case may be closed after advance notice, and public assistance offices will be notified, if applicable.
Public assistance includes, but is not limited to, the SNAP/TANF office, Medicaid office, and/or Child Care office.
• I understand the criminal penalties for making false statements and false swearing and do hereby attest to the truthfulness of the
information provided. [False swearing is punishable by a fine of not more than $1,000 or by imprisonment of one year or both.];
• If
I have an existing support order, upon paying the application fee for child support services, payments will be automatically directed to
MDHS. Upon my request to close my child support case, it is my responsibility to have the payments redirected in court;
• It is my responsibility to notify MDHS of any direct payments I receive from the noncustodial parent or any subsequent child support orders
I obtain;
• If I receive any money that was sent to me in error, the overpayment must be repaid by me;
• The state staff attorney and/or private contract attorney providing services pursuant to this application for child support services:
o Does not represent me in any action which may occur.
o Represents only the state and the state’s interest.
o Cannot give me any legal advice; further, I understand that if I want legal advice I should contact my own attorney.
o Does not deal with custody or visitation rights.
• That any monies herein paid by me are not attorney fees;
• I and/or the other parent each have the right to request a review, in writing, of the support obligation every three years to ensure the amount
is appropriately based on established guidelines, and this review may result in an increase or decrease in the child support obligation; and,
• No fee will be charged for parent locate only cases or Income Withholding Disbursement Services Only cases;
• I m
ust apply for and cooperate with child support enforcement as a condition of eligibility for a child care certificate and other public
assistance; and
• I must notify MDHS immediately when I have a change of address.
If I am requesting services as a custodial or other biological parent, I acknowledge that a child support worker will contact the noncustodial parent and
set up a meeting with him/her to attempt to reach an agreement to pay child support. The amount of child support will be based on his/her income. If
I have any information that has not been provided on this application and MDHS should know prior to this meeting (such as the noncustodial parents’
income, employer, etc.), I must contact the child support worker immediately. MDHS will use all information provided when determining the amount
of child support to be ordered.
If I am requesting services as a custodial parent, I understand my signature will serve as an authorization for MDHS to issue child support payments to
me on a debit card. I have received the disclosures related to the debit card transaction fees. I understand that I have the option to choose to enter into
a direct deposit agreement with MDHS instead. MDHS will issue payments on the debit card until I request to enter into a direct deposit agreement,
have completed and submitted the necessary forms, and have given MDHS and my financial institution reasonable time to setup direct deposit
transactions.
Under the penalty of perjury, I do hereby swear and affirm that I have read all the information provided on this application and that the
information I provided on this Application for Child Support Services is accurate and true to the best of my knowledge.
Applicant’s signature: Date: ______/______/_______
Please mail your completed application with a check or money order for $25.00 to:
MDHS-Division of Child Support
950 E. County Line Rd.
Suite G
Ridgeland, MS 39157