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W-2 Notice of Assignment

Notice of Assignment

Child Support, Family Support, Maintenance, and Medical Support

Information provided on this form (including any attachments) may be shared with others only for the purpose(s) or administration of the child support program and other related programs [s. 49.83, Wis. Stats.].

Child Support, Family Support and Maintenance:

I understand that the State has the right to collect court-ordered child support, family support and maintenance payments for me and any child in my care if I receive W-2 or Caretaker Supplement payments.
I understand that the State has the right to use part of the support to pay back the federal cost of W-2 or Caretaker Supplement payments I receive. I understand that support payments kept by the State cannot be more than the total amount of W-2 or Caretaker Supplement benefits my family receives.
I understand that the State will send me the amount of support allowed by federal and state law.
I understand that I will be notified of any changes that would affect my child support.
I understand that payments made on unpaid support that accrued when my family received AFDC will be used by the State to pay back AFDC costs and will not be sent to me.

Voluntary Support:

If the other parent pays child support directly to me, I must report all of it to my income maintenance worker and/or my W-2 Financial and Employment Planner.

Medical Support:

I understand that applying for Medicaid gives the State the right to collect medical support payments for my family's medical expenses that are covered by Medicaid. The medical support payments include those made under a court order and/or by an insurer.
I understand that the State has the right to use part of the medical support to pay back the cost of Medicaid benefits I receive. I understand that medical support payments kept by the Stat cannot be more than the total amount of Medicaid benefits my family receives. However, if my family no longer received Medicaid, the State has the right to collect medical support payments on past-due medical expenses covered by Medicaid.

Participant's Name:

Participant's Email Address:

Re: ss. 49.145(2)(f), Wis. Stats.

s. 49.45(19), Wis. Stats.

s.49.775(2)(bm), Wis. Stats.

DCF-F-DWSP2477 (R. 06/2010)

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Timestamp

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July 24, 2020 3:08 pm CDT

W-2 Notice of Assignment Uploaded by Brian Covey - bcovey@fsc-corp.org IP 75.135.161.21

July 27, 2020 9:45 am CDT

Eligibility Checklist - eligibilitychecklist@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81

January 27, 2021 1:01 pm CDT

Eligibility Checklist - eligibilitychecklist@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 75.135.161.21