Request For Release Of Joint Federal Tax Refund{04-1806}

Alaska Department of Revenue Please Reply To: CSSD, MS 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www.childsupport.alaska.gov Child Support Services Division All Case Numbers: _______________________________ Member Number: _______________________________ Request for Release of Joint Federal Tax Refund ___ Please return our joint tax refund to us. ___ Please apply our joint tax refund to the cases listed above. Release money to the custodial parent(s) and return over-collected amount to us. I, __________________________________ , the non-custodial parent's spouse, agree not to submit an injured spouse claim to the Internal Revenue Service (IRS) to replace the federal tax refund intercepted by the Child Support Services Division (CSSD). If any portion of the federal tax refund is reclaimed by the IRS, we understand that amount may be added to the arrears owed by __________________________________ , the non-custodial parent, and may be collected by withholding the non-custodial parent's wages or by other enforcement remedies. Current employer's name, address and phone number: ___________________________________ ___________________________________ ___________________________________ We understand and agree to the above. Non-Custodial Parent Signature: ______________________________ Date: ______________________________ Print Name: _____________________________ SSN: _____________________________ Address: ______________________________ ______________________________ Non-Custodial Parent's Spouse Signature: ______________________________ Date: ______________________________ Print Name: _____________________________ SSN: _____________________________ Address: _______________________________ _______________________________ SUBSCRIBED AND SWORN to before me this date: ____________________________________ ____________________________________ Notary Public in and for Alaska My Commission Expires:________________ SUBSCRIBED AND SWORN to before me this date: ____________________________________ ____________________________________ Notary Public in and for Alaska My Commission Expires:________________ Note: If a notary is not available, the signatures may be verified and stamped by a U.S. Post Office representative. CSSD 04-1806 (Rev. 10/02/12) 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