Form Cssd 04-1806 - Request Form For Release Of Joint Federal Tax Refund printable pdf download

Please Reply To:

Alaska Department of Revenue

CSSD, MS

Child Support Services Division

550 W. 7

Ave., Suite 310

Anchorage, AK 99501-6699

All Case Numbers: _______________________________

Member Number: _______________________________

Request for Release of Joint Federal Tax Refund

___ Please return our joint tax refund to us.

___ Please apply our joint tax refund to the cases listed above. Release money to the custodial parent(s) and

return over-collected amount to us.

I, __________________________________ , the non-custodial parent’s spouse, agree not to submit an injured

spouse claim to the Internal Revenue Service (IRS) to replace the federal tax refund intercepted by the Child

Support Services Division (CSSD).

If any portion of the federal tax refund is reclaimed by the IRS, we understand that amount may be added to the

arrears owed by __________________________________ , the non-custodial parent, and may be collected by

withholding the non-custodial parent’s wages or by other enforcement remedies.

Current employer’s name, address and phone number:

___________________________________

We understand and agree to the above.

Non-Custodial Parent

Non-Custodial Parent’s Spouse

Signature: ______________________________

Date:

______________________________

Date:

______________________________

Print Name: _____________________________

SSN:

_____________________________

SSN:

_____________________________

Address: ______________________________

Address: _______________________________

______________________________

_______________________________

SUBSCRIBED AND SWORN to before me this date:

____________________________________

Notary Public in and for Alaska

My Commission Expires:________________

Note: If a notary is not available, the signatures may be verified and stamped by a U.S. Post Office representative

CSSD 04-1806 (Rev. 10/02/12)

MAT-SU: (907) 357-3550

TOLL FREE (In-state, outside Anchorage): (800) 478-3300

SOUTHEAST: (907) 465-5887

ANCHORAGE: (907) 269-6900

FAX: (907) 787-3220

FAIRBANKS: (907) 451-2830

TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894

Form Cssd 04-1806 - Request Form For Release Of Joint Federal Tax Refund

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