DIVISION OF WELFARE AND SUPPORTIVE SERVICES SUPPORT ENFORCEMENT MANUAL
Section 200 MTL 4/09 1 Sep 09
EXHIBIT 200-2
(Page 1 of 2)
Non-Custodial
Parent Name:
SSN:
DOB:
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
NON-CUSTODIAL PARENT (NCP) FORM
When applying for TANF and/or Medicaid assistance, the law requires you to cooperate with Child Support Enforcement
(CSE) to establish paternity to get child support and/or medical support owed to you and/or any child(ren) that you are
applying for. This may include genetic testing. If the test proves the person you named is not the father, you may be
required to pay the cost of the test. You are also responsible for providing all available information requested by the CSE
Program such as certified copies of divorce decrees and/or support orders, birth certificates and photographs of the absent
parent.
The CSE Program locates absent parents and/or sources of income and assets, establishes and enforces financial and
medical support, reviews and adjusts existing child support orders, and collects and distributes financial and medical
support payments. If you are requesting medical assistance only, you may request in writing you only want medical
support services.
The CSE Program has sole discretion in determining which legal remedies are used in pursuing support and cannot
guarantee success. CSE may request assistance of another state, and thereby, be subject to the laws of that state. CSE
does not provide services involving custody, visitation or unpaid medical bills. CSE may close your case when your case
meets closure rules established by federal and state regulation.
The CSE Program represents the State of Nevada when providing services and no attorney-client privilege exists. CSE is
authorized to endorse and cash payments made payable to you for support payments and may collect past-due support by
intercepting an IRS tax refund or other federal payment. If a tax intercept occurs, the CSE Program has the authority to
hold a joint tax refund for a period of six (6) months before distributing the funds. No interest is paid on the held funds.
Funds collected from a tax intercept are applied first to pay off any past-due support assigned to the State of Nevada. A
nonrefundable fee is deducted by the federal government of any tax or federal payment intercepted by the CSE Program.
Good cause for not cooperating in pursuing child support or paternity may be allowed. If you do not cooperate with CSE
and good cause has not been determined, your household will be ineligible for TANF and you will be ineligible for
Medicaid. Good cause for not cooperating will be considered if you request it in writing. Examples of good cause are as
follows:
● The child was conceived as a result of rape or incest.
● Legal proceedings for adoption of the child are pending before a court.
● You are being assisted by a public or licensed private social service agency to decide whether to keep or
relinquish the child for adoption (no longer than three (3) months).
● Your cooperation in establishing paternity or securing support will result in physical or emotional harm
to yourself or the child(ren).
You must provide your case manager with verification within twenty (20) days after claiming good cause. You will
receive written notification of the good cause decision. If you are found to have good cause for not cooperating, CSE will
NOT attempt to establish paternity or collect child support.
YES, I wish to claim good cause. NO, I do not wish to claim good cause at this time.
_______________________________________________
Signature
You must report changes whenever a name change occurs; you have a new address or telephone number for home or
work; you hire a private attorney or collection agency; another child support or paternity legal action is filed; you file for
divorce; you receive support payments directly from the absent parent; you have a new address, telephone number,
employment or health insurance for the absent parent; a child(ren) no longer lives with you; a child(ren) is still in high
school after age 18; a child(ren) becomes disabled before age 18; a child(ren) comes to live with you or you birth another
child; a child marries, is adopted, joins the armed forces or is declared an adult by court order.
You are responsible for repayment of support amounts received in error, including payments from an IRS tax refund,
which are adjusted by the IRS. If you fail to enter into a repayment agreement with the CSE Program, the outstanding
balance may be reported to a credit reporting agency and money collected on your behalf by the CSE Program may be
withheld for repayment. Additionally, legal action may be initiated against you.
(Side 1) 2906 – EG (6/07)