Home Investment Partnership (Home) Program - Support Information On Children - Affidavit
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1Oakland County Community & Home Improvement
Home Investment Partnership (HOME) Program
Support Information on Children
Applicant:
Address:
Case No.
Please complete the following information:
List the Children (under 18) living in your household at least 50% of the
time
First Name
Last Name
Age
1
2
3
4
Do you receive Child Support?
YES
NO
If yes:
Submit a copy of child support history for the last 6 months, known as the Court Order Information Report:
You can request the report in person at: Oakland County Friend of Court, Banking Dept,
230 Elizabeth Lake Rd., Pontiac, MI 48341
-or-
By phone at: Toll free at (888) 350-0900 Ext. 81565
If no:
Submit a copy of your Judgment of Divorce, stating that no child support was ordered.
Additional Support Information to be considered:
Do you receive Social Security for your children?
YES
NO
If yes: Submit a copy of your Annual Social Security Award Letter(s)
Do you receive Public Assistance?
YES
NO
If yes: Submit a copy of your Award Letter
CERTIFICATION: This statement is true to the best of my knowledge and belief.
PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S.C. Title 18, Sec. 1001, provides:
Whoever, in
any matter within the jurisdiction of any department or agency of the United Sates knowingly and willfully
falsifies...or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false
writing, or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be
fined not more than $10,000 or imprisoned not more than 5 years, or both."
__________________________/______________________________________/____________
Printed Name
Signature
Date signed
HIP Forms
Affidavit/CS
4/2015
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