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Government of the Virgin Islands of the United States



DEPARTMENT OF HUMAN SERVICES



Office of Childcare & Regulatory Services



STATEMENT FOR

VERIFICATION OF CHILD SUPPORT



I, , certify that I provide $ for

support of my child/children.



Weekly Bi-Weekly Monthly Bi-Monthly



Name of Child or Children:



Physical address:



Signature Date



Sworn To and Subscribed Before Me



This Day of

on St. Croix, USVI.



Commission #:

Exp. Date:



Knud Hansen Complex Bldg. A * 1303 Hospital Ground « St. Thomas, Virgin Islands 00802 » (340) 774-0930

3011 Golden Rock ¢ Christiansted, St. Croix, Virgin Islands 00820 (340) 718-2980