Child Support Referral & Assignment – Quinault Indian Nation

A Child Support Referral and Assignment must be completed if there are not two biological or adopted parents in the home.

Please know that incomplete referrals and assignments will delay the processing time for a determination of eligibility. Information is required on the custodial parent(s), non-custodial parent(s) and children.

If children do not have the same mother and father, a separate referral must be completed.

If you have questions or need assistance in completing the Child Support Referral, please ask.

The Quinault Indian Nation Child Support Program will use your Social Security Number for child support enforcement purposes as defined in Title IV-D of the Social Security Act.

Prefer to download a PDF of this form?

If you would prefer to download and either fill in digitally or print this form, it is available as a PDF:

Child Support Referral & Assignment

Then submit by:

email to TANF@quinault.org
bringing to any of our offices either during normal business hours or leaving in one of the drop-boxes anytime
by fax: 360-537-1265

Head of Household Information

Head of Household Name(Required)

First Middle Last

Relationship to child(Required)

Do you have legal custody(Required)

Yes

Who has legal custody?

Head of Household Address(Required)

Street Address City State ZIP Code

Court Orders

Is an attorney currently working on the child support case?(Required)

Yes

What is the name and phone number of the attorney?

Date of Order or Filed

Court Case Number

What Court?

City

County

State

Was child support ordered?(Required)

Yes

If Yes, provide support of the order.

Placement Agency

Is the child/ren in Indian Child Welfare or Child Welfare custody?(Required)

Yes

What agency?

Non-Custodial Parent(s) Information

Relationship between mother and father of child/ren?(Required)

Never Married

Married/Living Together

Married/Separated

Divorced

Mother's Information, if Not Custodian

Is the mother deceased?

Yes

Has the mother been deported?

Yes

Mother's Name

First Middle Last

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security Number

Date of Birth

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Income per hour

Income per month

Has a second job?

Yes

If yes, where

In jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Father's Information, if Not Custodian

Is the father deceased?

Yes

Has the father been deported?

Yes

Father's Name

First Middle Last

Physical Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Phone Number

Message Number

Social Security Number

Date of Birth

Enrolled member of a federally recognized Indian tribe?

Yes

If yes, name of tribe

Lives on an Indian reservation?

Yes

Currently Married?

Yes

If yes, to whom

Employer's Name

Employers Phone

Income per hour

Income per month

Has a second job?

Yes

If yes, where

In jail or prison?

Yes

If yes, where

Vehicle Year

Vehicle Make

Vehicle Model

In Military?

Yes

Branch

From

Child Information 1

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name(Required)

First Middle Last

Social Security #(Required)

Date of Birth(Required)

Place of Birth City, County, State, Country(Required)

Gender(Required)

Female

Male

Race(Required)

Enrolled member of a federally recognized Indian tribe?(Required)

Yes

Name of tribe

Enrollment Number

Child Information 2

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

Name of tribe

Enrollment Number

Child Information 3

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

Name of tribe

Enrollment Number

Child Information 4

Please note that if children have a different mother and father then a separate referral must be completed.

Child Name

First Middle Last

Social Security #

Date of Birth

Place of Birth City, County, State, Country

Gender

Female

Male

Race

Enrolled member of a federally recognized Indian tribe?

Yes

Name of tribe

Enrollment Number

Agreement, Consent and Limited Power of Attorney

Quinault Indian Nation Child Support Services Program use Social Security numbers for child support enforcement as defined in Title IV-D of the Social Security Act.

Head of Household Name(Required)

Social Security Number(Required)

Child's Name(Required)

Social Security Number(Required)

Child's Name

Social Security Number

Child's Name

Social Security Number

Child's Name

Social Security Number

When you accept a QIN TANF monthly cash grant, you are assigning your child support and medical support rights to the Quinault Indian Nation. When you agree to assign your support rights, you are agreeing Quinault Indian Nation may keep your support payments to repay the Quinault Indian Nation and the federal government for assistance that is paid to your family.

When you accept a QIN TANF monthly cash grant, you are agreeing to cooperate with the Quinault Indian Nation and the Washington State Division of Child Support by:

Helping to establish paternity, if applicable.
Helping to establish or modify your support order.
Sending all support payments that you directly receive from the non-custodial parent to:

QIN Child Support Services
PO Box 689
Taholah, WA 98587

Washington State Support Registry
PO Box 45868
Olympia, WA 98504-5868
Appointing DCS and/or the Quinault Indian Nation to accept and endorse all child, spousal and medical support payments.
Informing QIN TANF in writing when you no longer want child support enforcement services. When you stop receiving a QIN TANF monthly cash grant, child support will continue to be enforced unless you request services be stopped.

Signature(Required)

Date

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Password

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