This questionnaire is for applicants who have contacted their child support enforcement agency, and are dissatisfied with the help they have received from them.

Applicant’s name: ______Date: ______

  1. For each child:

Name / dob / M/F / Mother / Father on birth certificate* / Your relationship
(if not parent)
______/ ____ / ____ / ______/ ______/ ______
______/ ____ / ____ / ______/ ______/ ______
______/ ____ / ____ / ______/ ______/ ______
______/ ____ / ____ / ______/ ______/ ______
______/ ____ / ____ / ______/ ______
  1. On what date did you last apply for child support enforcement services from your local county child support enforcement (IV-D) agency?
  2. In what county?
  1. What is the name of your child support technician?
  1. What is the Child Support Enforcement Agency case number?
  1. What is the District Court Case number, if any?
  2. Are you satisfied with the work that agency is doing for you? yesno

If no, say: Colorado Legal Services does not represent people to collect child support. We may be able to refer your case to the Colorado Division of Child Support Enforcement to review your case to make sure it is being handled in compliance with the program’s rules and regulations. Would you like us to review your case to see whether we can refer it to the State Office?  yes  no If yes, do we have your permission to send your information to the State Office?  yes  no If yes to both of these questions, complete the rest of this questionnaire. If not, stop here.

  1. Have you ever received Colorado Works/TANF benefits for these children? yesno
  2. If yes, are you currently receiving Colorado Works/TANF benefits for these children? yes no
  3. If yes, what is your monthly benefit amount? $
  1. Which of these best describes the history of child support collection?

 I have received all of my child support.

 I have never received any child support.

 I have not received any child support payments since date.

 I have received only sporadic child support payments totaling $ from

(date) to (date)

  1. How much total back child support do you believe you are owed? $
  2. Do you know where the person who owes child support is working? yesno

If yes, where?

  1. What do you think is wrong with the quality of services the county child support enforcement agency has provided to you?
  1. What do you think the county child support agency has done to collect child support in your case?
  1. Has the county child support agency collected any child support for you? yesno
  2. If yes, how much? $
  3. How much did the child support agency keep from what they collected? $
  1. Additional information or advice given:

S:\intake\Rene\in process\questionnaires\IV-D questionnaire.doc revised 2009