Withdrawal From Services {04-1090}

Alaska Department of Revenue Please Reply To: Child Support Services Division CSSD 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www.childsupport.alaska.gov WITHDRAWAL FROM SERVICES I no longer want any services from the Child Support Services Division. Please stop processing child support payments for my case and close the case. I understand that if: (1) there is any child support debt to the State of Alaska, CSSD will continue to collect on behalf of the State; (2) the other case party applied for services, the case will not be closed unless he or she withdraws from services and; (3) the children have not emancipated, the child support order is still in effect. Even though CSSD is not collecting on the case, child support is still owed. I understand that I may reopen my case by applying for services at some future date. Names and birth dates of the child(ren) in my custody for whom I request withdrawal from services are: DOB DOB DOB DOB DOB DOB Request made this ________ day of __________________________, 20______. Signature Date Home Phone Work Phone Printed Name Mailing Address Case Number Member Number City State Zip CSSD 04-1090 (Rev 04/09/2012) 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 American LegalNet, Inc. www.FormsWorkFlow.com