IOCI19-0705HFS 2745 (R-9-13)

ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES Division of Child Support Services

CLEAN SLATE BALANCE REDUCTION APPLICATIONTHIS APPLICATION IS THE 1ST STEP IN REDUCING MY CHILD SUPPORT DEBT.

Este es un aviso muy importante. Si usted no entiende este aviso, comuníquese con el Centro de Servicio al Consumidor en la Sección de Manutención de Niños a 1-800-447-4278, dónde le podrán explicar este aviso. Personas que usan teletipo (TTY) deben llamar a 1-800-526-5812. This is an important notice. If you do not understand this notice, contact the Child Support Customer Service Call Center at 1-800-447-4278 who can explain it to you. Persons with a TTY device may call 1-800-526-5812.

Some of the child support debt that I owe is owed to the State of Illinois as reimbursement for public assistance (welfare), and the remainder is owed to the custodial parent.

The State needs the information below to process the debt reduction application.

Name:

Address:

Daytime phone number:

Current employer(s) name:

Employer phone number:

Last 4 digits of SSN: xxx-xx-

Date of birth:

SingleMarriedMarital Status:

Number of people in my household:

MY RESPONSIBILITIES (You must initial each statement below or your application will be rejected)

My Child(ren)'s Name(s):

Initial here

I understand that to be eligible for consideration for this Program, that support must currently be owed to both the State and the custodial parent for my child(ren) listed above.

I understand that only the support that is owed to the State for my child(ren) listed above may be reduced.Initial here

I understand that the amount of support I owe to the custodial parent for my child(ren) listed above will not be reduced and must be paid.Initial here

I authorize the Department to check my credit report to verify my income.Initial here

Initial hereIf my application is approved, I will sign a payment plan to pay my support obligation.

I understand that the Department will use available methods to collect current and past due support owed to the custodial parent.

Initial here

I have not committed or been convicted of a crime against my children or the custodial parent(s) of my child(ren).Initial here

Date

NCP RIN:Office Use Only

Peoria Regional Office 401 Main Street, Suite 680 Peoria, IL 61602

E-mail address:

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Signature