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Child Suport Forms in Minnesota

Child Support Forms from Minnesota Department of Human Services

You will need the free Adobe Acrobat Reader to view, print, and save some of these publications which are in the Portable Document Format (PDF) and shown with the PDF icon (DHS image).

 
Automatic Withdrawal for Your Child Support Payments (DHS-4117) This form authorizes and explains automatic recurring withdrawal as an option for obligors who have an open child support case but are not court-ordered to pay by income withholding.

 
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Direct Deposit for Child Support (DHS-3371) This form explains the benefits of directly depositing child support to checking and savings accounts and includes a Direct Deposit Authorization form.

 
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DHS image Hmong

 
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Explanation of Child Support (IV-D) and Income Withholding-Only (Non-IV-D) Services in Minnesota (DHS-2973) This form is used to explain child support services available to applicants. The form explains the difference between IV-D and Non-IV-D services.

 
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Financial Affidavit for Child Support (DHS-4912) The financial affidavit form is used to disclose all sources of income when determining support for joint children.

 
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Full Child Support (IV-D) Services Application (DHS-1958) This form is used by an applicant who is not receiving public assistance and wants to apply for county child support enforcement services. The form includes an application, describes the services available, and explains the applicant's responsibilities.

 
DHS image English

 
DHS image Hmong

 
DHS image Somali

 
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Income Withholding-Only (Non-IV-D) Services Application (DHS-3164) This form is used to apply for Non-IV-D Services. The county child support enforcement agency will use this information to process Non-IV-D automatic income withholding.

 
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DHS image Hmong

 
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Minnesota Husband's Non-paternity Statement Revocation Form (DHS-3159e) This is a legal form to cancel a previously signed Husband's Non-paternity Statement.

 
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DHS image Hmong

 
DHS image Somali

 
DHS image Spanish

 
Minnesota Voluntary Recognition of Parentage (DHS-3159) This is a legal form to voluntarily establish paternity for a child born to parents who aren't married to each other.

 
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DHS image Hmong

 
DHS image Somali

 
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Minnesota Voluntary Recognition of Parentage Revocation Form (DHS-3159b) This is a legal form to cancel voluntary paternity establishment created by a previously- signed and filed Recognition of Parentage form.

 
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DHS image Hmong

 
DHS image Somali

 
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Minnesota Voluntary Recognition of Parentage Husband's Non-paternity Statement (DHS-3159c) This is a form a husband can sign when he is not the father of his wife's child. Signing this form ends the legal relationship between a presumed father and child when a Voluntary Recognition of Parentage Form is also signed and filed.

 
DHS image English

 
DHS image Hmong

 
DHS image Somali

 
DHS image Spanish

 
Referral to Support and Collections (DHS-3163b) This form is used by MinnesotaCare and Medical Assistance recipients for referral to the local child support agency to establish paternity or child support enforcement services.

 
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DHS image Hmong

 
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Request for Exception to Direct Deposit (DHS-4583) The State of Minnesota, Child Support Enforcement Division now sends support payments by direct deposit. This form is used to request an exception to direct deposit.

 
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Request to Close Support Case (DHS-4060) This form is used by people who applied for child support services to request to close their case.

 
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Stored Value Card (DHS-4533) This form is used to sign up to have child support payments loaded to a prepaid U.S. Bank ReliaCardŽVisa.

 
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Unreimbursed and/or Uninsured Medical Dental Expenses Packet (DHS-4931-ENG) This packet is for the collection of unreimbused and/or uninsured medical or dental expenses from the requesting party to the non-requesting (liable) party. The packet contains the information, notice, and instructions for the requesting party, and the notice of intent to collect the unreimbursed and/or uninsured medical expenses and the affidavit that will be completed by the requesting party and sent to the non-requesting (liable) party.

 
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Unreimbursed and/or Uninsured Medical Dental Expenses Packet (DHS-4931-ENG) This packet is for the collection of unreimbused and/or uninsured medical or dental expenses from the requesting party to the non-requesting (liable) party. The packet contains the information, notice, and instructions for the requesting party, and the notice of intent to collect the unreimbursed and/or uninsured medical expenses and the affidavit that will be completed by the requesting party and sent to the non-requesting (liable) party.






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