Form Cssd 04-1606d - Statement Of Support Provided
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2STATEMENT OF SUPPORT PROVIDED
See instructions on the next page.
If you provided no support, please submit this statement with the “no support provided” options checked in Items 4 and 5.
1. Your name ____________________ CSSD Case # ____________ Custodial parent’s name ___________________
2. You are the noncustodial parent of these minor children:
Child’s full name
Date of birth
Child’s full name
Date of birth
Check all the appropriate boxes in items 3-6, and complete the table below (or submit separate pages if necessary).
3.
An administrative order from
A court order requires you to pay
No administrative or court
CSSD or another child support
OR
child support
OR
order for child support is in
agency requires you to pay child
alimony
spousal support)
effect at this time.
(
support.
4.
List in the table below the
If you aren’t sure how much
You have paid no child
child support payments you have
OR
child support you’ve paid the
support to the custodial
OR
paid to the custodial parent.
custodial parent, list your best
parent.
Don’t forget to indicate the
estimate by month and year in the
year(s).
table below (or on a separate page).
5.
List in the table below the
If you aren’t sure how much
You have paid no alimony
alimony (spousal support) you
OR
alimony (spousal support) you’ve
OR
(spousal support) to the
have paid the custodial parent.
paid the custodial parent, list your
custodial parent.
Don’t forget to indicate the
best estimate by month and year in
year(s).
the table below (or on a separate
page).
6. If a child support order is already in effect, did you live with the other parent (or has the other parent had custody of the
children) at any time since the order was issued?
Yes
No
If your answer is yes, attach a description of the
time periods when you lived together (or when the other parent had custody) since the child support order was issued.
Year:
Child Support
Alimony/
Year:
Child Support
Alimony/
Year:
Child Support
Alimony/
Spousal
Spousal
Spousal
Jan
Jan
Jan
Feb
Feb
Feb
Mar
Mar
Mar
Apr
Apr
Apr
May
May
May
Jun
Jun
Jun
July
July
July
Aug
Aug
Aug
Sep
Sep
Sep
Oct
Oct
Oct
Nov
Nov
Nov
Dec
Dec
Dec
Signature
Date _______________________
______________________________________________
CSSD main office mailing address:
th
550 W 7
Ave Suite 310
Anchorage AK 99501-6699
CSSD 04-1606D (Rev. 03/16/06) (2 p.)
Statement of Support Provided (3 yr version)
Page 1 of 2
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