PO Box 28450
Commonwealth of Virginia Richmond, VA 23228
Department of Social Services http://www.dss.virginia.gov/family/dcse/
Division of Child Support Enforcement 1-800-468-8894
Statement of Payments
Please be mindful to carefully follow the instructions as you complete this document. If you do not return the document
on time, the Division may not be able to initiate action to establish the arrearages on this case.
Division Case Number:___________________________
Custodial Parent Name:__________________________ Noncustodial Parent Name:________________________
I am the: ☐ Custodial Parent ☐ Noncustodial Parent
I have: ☐ An administrative support order for child support
☐ A court order for child support
☐ A court order for child support and spousal support/alimony
I ☐ have or I ☐ have not received Temporary Assistance for Needy Families (TANF). If you have received TANF please provide
the name of the agency and time period below:
__________________________________________________________ ____________________________________________
Agency Name, City and State Time Period
Please check all options below that apply to you. If more than one option applies, complete the section for each option you
check. You must read and sign the certification on the last page and return to the Division.
Custodial Parent:
☐ I have never received any child support payments. (Complete Section A)
☐ I have received child support payments from a child support agency or court. (Complete Section B)
☐ I have received child support payments from a private child support company. (Complete Section C) ☐ I
have received child support payments directly from the noncustodial parent. (Complete Section D)
Noncustodial Parent:
☐ I have never paid any child support payments. (Complete Section A)
☐ I have paid child support payments through a child support agency or court. (Complete Section B)
☐ I have paid child support payments through a private child support company. (Complete Section C)
☐ I have paid child support payments directly to the custodial parent. (Complete Section D)
Section A
If you have never received or paid any child support payments and/or spousal support payments through any source, check the
box below, read and sign the certification on the last page and return to the Division. (You do not need to complete Sections B-
D.)
☐ I have not received or paid any child support payments and/or spousal support payments through a child support agency,
court or private child support company. I have never received support directly from the noncustodial parent. I have never paid
support directly to the custodial parent.
Section B
If you have ever received or paid child support and/or spousal support payments through a child support agency or court, indicate
the name(s) of the agency and/or court below. If more than one agency and/or court, list first the agency or court through which
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B032-35-0094-03-eng rev 05/2020
PO Box 28450
Commonwealth of Virginia Richmond, VA 23228
Department of Social Services http://www.dss.virginia.gov/family/dcse/
Division of Child Support Enforcement 1-800-468-8894
you most recently received or made payments. If you are still receiving or making payments through the court or agency, check
the appropriate box.
1. Name and address of child support agency/court: __________________________________________________
__________________________________________________ ☐
I still receive payments from this agency/court
2. Name and address of child support agency/court: __________________________________________________
__________________________________________________
☐ I still receive payments from this agency/court
If you have a copy of the payment history or an arrears statement, please provide that information to the Division. We
may also contact you for additional documents and information.
Section C
If you have ever received or made child support payments through a private child support company, check any of the following
that apply to you and provide the name and address of the private company.
Name and address of private child support company: __________________________________________________
__________________________________________________
__________________________________________________
☐ I have a copy of the contract I signed. ☐ I am attaching a copy of the contract.
☐ I have a copy of a payment history from this company. ☐ I am attaching a copy of the payment history.
☐ I still have services or am under contract to this company.
Section D
If you are the custodial parent and have ever received any child support and/or spousal support payments directly from the
noncustodial parent or if you are the noncustodial parent and you have ever made child support and/or spousal payments
directly to the custodial parent, fill in this section. Read the instructions below before you fill out this section. Complete the
following tables to show the month and year that you received or made direct payments. Failure to complete this form correctly
could delay enforcement actions.
Instructions: Start with the first month and year you were entitled to receive support or pay support and continue through to
the current month and year. Tables should contain only direct payments from the noncustodial parent to the custodial parent.
For any month support was due and payment was not made, enter $0.
Example: You have an order for child support. The noncustodial parent was ordered to pay $300 per month in child
support (no spousal support) starting March 1, 2010.
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B032-35-0094-03-eng rev 05/2020
PO Box 28450
Commonwealth of Virginia Richmond, VA 23228
Department of Social Services http://www.dss.virginia.gov/family/dcse/
Division of Child Support Enforcement 1-800-468-8894
Year: Child Spousal /
2010 Support Alimony
Jan N/A N/A
Feb
N/A
Mar
Apr 300.00
May
300.00
Jun
Jul 0.00
Aug
Sep 150.00
Oct
Nov 275.00
Dec 300.00
300.00
List all payments that were received/paid directly from _____________________ to
_________________________. 225.00
300.00
300.00
Year: Year: Child Spousal / Year: Child Spousal /
Support Alimony Child Spousal / Support Alimony
Jan Jan Jan
Support Alimony
Feb Feb Feb
Mar Mar Mar
Apr Apr Apr
May May May
Jun Jun Jun
Jul Jul Jul
Aug Aug Aug
Sep Sep Sep
Oct Oct Oct
Nov Nov Nov
Dec Dec Dec
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B032-35-0094-03-eng rev 05/2020
PO Box 28450
Commonwealth of Virginia Richmond, VA 23228
Department of Social Services http://www.dss.virginia.gov/family/dcse/
Division of Child Support Enforcement 1-800-468-8894
Year: Year: Child Spousal / Year: Child Spousal / Child Spousal /
Support Alimony Support Alimony Support Alimony
Jan Jan Jan
Feb Feb Feb
Mar Mar Mar
Apr Apr Apr
May May May
Jun Jun Jun
Jul Jul Jul
Aug Aug Aug
Sep Sep Sep
Oct Oct Oct
Nov Nov Nov Dec Dec Dec Year: Year: Year:
Jan Jan Jan
Feb
Feb Feb
Mar Mar Mar
Apr Apr Apr
May May May
Jun Jun Jun
Jul Jul Jul
Aug Aug Aug
Sep Sep Sep
Oct Oct Oct
Child Spousal / Child Spousal / Child Spousal /
Nov Nov Nov
Support Alimony Support Alimony Support Alimony
Dec Dec Dec
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B032-35-0094-03-eng rev 05/2020
PO Box 28450
Commonwealth of Virginia Richmond, VA 23228
Department of Social Services http://www.dss.virginia.gov/family/dcse/
Division of Child Support Enforcement 1-800-468-8894
Year: Child Spousal / Year: Year: Child Spousal / Child Spousal /
Support Alimony Support Alimony Support Alimony
Jan Jan Jan
Feb Feb Feb
Mar Mar Mar
Apr Apr Apr
May May May
Jun Jun Jun
Jul Jul Jul
Aug Aug Aug
Sep Sep Sep
Oct Oct Oct
Nov Nov Nov
Dec Dec Dec
Certification: I hereby certify under penalty
of perjury that all information I provided in this
document is true and correct to the best of my
knowledge and belief.
Signature_______________________________________________ DATE _____________________________
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B032-35-0094-03-eng rev 05/2020
