Request to Change Payment Collection Method form

CHANGING TO DEPARTMENT OF HUMANSERVICES COLLECTNote: If you are requesting that we collect payments on yourbehalf and this is not the first time you have made this request,we may not accept this application.9 In addition to collecting your ongoingpayments, do you want us to collect anyoutstanding private payments?No Go to 11.10 Do you believe you have exceptionalcircumstances which prevented you fromapplying for collection earlier?If the paying parent owes you child support for the last 9months, you may be eligible to recover these payments. Pleaseprovide information if you believe exceptional circumstanceshave prevented you from applying for collection earlier.No Go to 11.YesCircumstancesPlease provide information below.YesPlease complete the table below.We can collect up to 3 months of arrears if payments have notbeen made during this time.Please state the amounts owing to you and the periods theseamounts cover.Amount dueAmount paid$$11 What are the paying parent’s employmentdetails? (if known)Employer nameDate paid / /Period the payment covers from/ / to/ /Employer addressAmount due$Amount paid$Date paid / /Period the payment covers from/ / toAmount due$/ /Employer phone number( )Employer mobile phone numberDo you know any other details that might help us to locate thepaying parent? (e.g. The name of the paying parent’s bank orbusiness income, or the name and contact details of a personwho might know.)Amount paid$Date paid / /Period the payment covers from/ / to/ /1979.12053 of 4