dhs-998, STATEMENT OF ASSISTED REPRODUCTIVE TECHNOLOGY

Michigan Department of Health and Human Services (MDHHS)

Office of Child Support (OCS)

(Revised 12-23)

section 1 – personal information

Name	Date of Birth	Date

Address	City	State	Zip Code

Telephone	Email

section 2 – child support case number(s) (if known)

section 3 – assisted reproductive technology

Assisted reproductive technology includes intrauterine insemination, donation of eggs, donation of embryos, in vitro fertilization and transfer of embryos, and intracytoplasmic sperm injection.

Assisted Reproductive Technology Was Used to Conceive (Enter children’s names and dates of birth below)

Details of Assisted Reproductive Technology Used

section 4 – Signature

By signing this form, I attest that I have provided truthful information about the use of assisted reproductive technology for the child(ren) named in this form. I also understand that I will no longer receive child support services, and my child support case will be closed.

Signature	Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

GENERAL INSTRUCTIONS FOR COMPLETING

THE STATEMENT OF ASSISTED REPRODUCTIVE TECHNOLOGY

PURPOSE OF FORM:

People who receive some types of public assistance must help the child support program establish paternity and/or child support for children in their care. If you used assisted reproductive technology to conceive your child(ren) and you do not want child support services, you can complete this form and return it to:

Michigan Department of Health and Human Services

Office of Child Support

PO Box 30478

Lansing, MI 48909

Sign and date the form in the appropriate boxes and mail the completed form within 21 days of receipt, along with supporting documentation.

If you want help in the future, you can request child support services by completing an online application at: www.michigan.gov/michildsupport or calling 866-540-0008.

The child support program offers many important services.

SECTION 1 – PERSONAL INFORMATION:

Name: Enter your full name (first name, middle name, and last name);

Date of Birth: Enter the month, day and year you were born;

Date: Enter today’s date;

Address: Enter your current street address;

City: Enter the city where you live;

State: Enter the state where you live;

Zip Code: Enter your Zip code;

Telephone: Enter a telephone number, including area codes; and

Email: Enter your email address, if available.

Note: The Office of Child Support will use the above information to locate your case and/or contact you for more information if necessary.

SECTION 2 – CHILD SUPPORT CASE NUMBER(S) (if known):

Enter your IV-D case number, court action referral number, or court case number, if known. You may find these numbers on forms and notices that the child support program has sent you.

SECTION 3 – ASSISTED REPRODUCTIVE TECHNOLOGY

Assisted Reproductive Technology Was Used to Conceive:

Enter the names and dates of birth for all children you conceived using assisted reproductive technology. Assisted reproductive technology refers to treatments and/or procedures that aim to achieve pregnancy.

Details of Assisted Reproductive Technology Used:

Enter details of the assisted reproductive technology you used (intrauterine insemination, donation of eggs, donation of embryos, in vitro fertilization and transfer of embryos, and intracytoplasmic sperm injection, etc.). Also provide supporting documentation such as formal or informal agreements or correspondence with the donor, receipts for genetic materials, and/or receipts for related medical procedures.

Note: To protect your medical privacy, do not include medical records.