Form Cssd 04-1606d - Statement Of Support Provided (Page 2 of 2) in pdf

Instructions for Completing the Statement of Support Provided

1. Enter your name, the CSSD case number (if you have a CSSD case already and you know the number) and the name

of the noncustodial parent.

2. Enter the full name and date of birth for each child.

3. If there is an administrative support order from Alaska or another state, check the first option. If there is a court order,

check the second option, and indicate whether the court order includes child support, alimony (spousal support), or

both. If there is both a court order and an administrative order, check both the first and second options. If there is no

order of any kind, check the third option.

4. If you have provided child support to the custodial parent, check the first option and complete the “Child Support”

column in the table on the bottom of the page. Don’t forget to indicate the year(s). See example below. If you have

provided support during more than three years, copy the first page or ask CSSD for the long version of this statement.

If you have provided some child support, but you are not sure when or how much, check the second option and enter

your estimates in the table (mark them as “estimates”). Or you may submit estimates on a separate page. If you have

provided no child support at any time, check the third option.

NOTE: If the custodial parent or the child is receiving government benefits from Social Security, the Veterans

Administration, or another government agency, and the benefits are based on your disability or retirement, these

benefits may be credited toward your support obligation. Please provide information about such benefits on a

separate page.

5. If you have provided alimony or spousal support to the custodial parent, check the first option and complete the

“Alimony/Spousal” column in the table. Don’t forget to indicate the year(s). See example below. If you have

provided support during more than three years, copy the first page or ask CSSD for the long version of this statement.

If you have provided some spousal support, but you are not sure when or how much, check the second option and

enter your estimates in the table (mark them as “estimates”). Or you may submit estimates on a separate page. If you

have provided no alimony or spousal support at any time, check the third option.

6. If a child support order is already in effect, and you lived with the other parent or the other parent had custody of the

child at any time since the child support order took effect, please check the “Yes” box and attach a written explanation

Table: Start with the first month and year you were supposed to pay support, and continue through the current month and

year. Add additional pages, if necessary. Enter “0” in months when no support was provided. For example, if the child

support order says you should have provided $250 child support per month beginning in June of 2000, and no spousal

support, and the you paid irregularly and never paid the full monthly child support amount, your “support provided table”

might look like this in December 2001:

Year

Child

Alimony/

Year

Child

Alimony/

Support

Spousal

2000

2001

Support

Spousal

N/A

Jan

$75

Feb

$50

Mar

Apr

May

$100

$75

Jun

$175

Jul

$150

Aug

$150

Sep

$200

Oct

$225

$100

Nov

$175

Dec

CSSD 04-1606D (Rev. 03/16/06) (2 p.)

Statement of Support Provided (3 yr version)

Page 2 of 2

Form Cssd 04-1606d - Statement Of Support Provided Page 2

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