Fill and Sign the Child Support Form 497330285

CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS Petitioner [ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services Respondent [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) File Stamp [ ] Non-IV-D To : (Agency Name and Address) Responding FIPS Code ________________ State _________________________ Responding IV-D Case No. ____________________________________________ Responding Docket No. _______________________________________________ From : (Contact Person, Agency, Address, Phone, Fax, Internet) Initiating FIPS Code __________________ State __________________________ Initiating IV-D Case No. _______________________________________________ Initiating Docket No. __________________________________________________ Send Payments To: (if diferent from above) Payment FIPS Code ___________________ State ________________________ Bank Account ________________________ Routing Code _________________ Initiating Jurisdiction [ ] URESA [ ] UIFSA State with Continuing Exclusive Jurisdiction (CEJ) ________________ I. Action 1. [ ] Status Request 7. [ ] Status Update 2. [ ] Notice of Hearing 8. [ ] Notice of Case Forwarding 3. [ ] Document Filed 9. [ ] Order Issued/Confrmed 4. [ ] Notice of Arrearage Reconciliation/Determination of Sum-Certain 5. [ ] Change of Payee/Redirection of Payment 6. [ ] Other ____________________________________________________________________________________________ ____________________________________________________________________________________________ [ ] Please Return the Acknowledgment Attached (2 of 2) II. Additional Information Child Support Enforcement Transmittal #2 - Subsequent Actions OMB No. 0970 - 0085 Page 1 of 2 _________________ _____________________________ (________)___________________________ Date Initiating Contact Person (Print or Type) Telephone Number & Extension (________)___________________________ Fax Number Child Support Enforcement Transmittal #2 - Subsequent Actions OMB No. 0970 - 0085 Page 1 of 2 CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS Petitioner [ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services Respondent [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) File Stamp [ ] Non-IV-D To : (Agency Name and Address) Responding FIPS Code ________________ State _________________________ Responding IV-D Case No. _____________________________________________ Responding Docket No. _______________________________________________ From : (Contact Person, Agency, Address, Phone, Fax, Internet) ____________________________________________________________ Initiating FIPS Code __________________ State: __________________________ Initiating IV-D Case No. ________________________________________________ Initiating Docket No. ___________________________________________________ Send Payments To: (if diferent from above) Payment FIPS Code ___________________ State _________________________ Bank Account ________________________ Routing Code ___________________ Initiating Jurisdiction [ ] URESA [ ] UIFSA State with Continuing Exclusive Jurisdiction (CEJ) _________________ ACKNOWLEDGMENTS Return This Form to Initiating State [ ] Request Received and No Additional Information is Necessary [ ] Additional Information Needed (See Remarks) [ ] Remarks/Response Child Support Enforcement Transmittal #2 - Subsequent Actions Return This Page to the Initiating Jurisdiction Page 2 of 2 Child Support Enforcement Transmittal #2 - Subsequent Actions Return This Page to the Initiating Jurisdiction Page 2 of 2 [ ] Your Case has been Forwarded for Action to: __________ _ Name of Worker _____________ Agency Name _____________ Address, FIPS Code ___________ Phone & Extension ___________ Fax ___________________ _______________________________ (_________)_____________________ Date Person Completing Form (Print or Type) Telephone Number & Extension (_________)_____________________ Fax Number Child Support Enforcement Transmittal #2 - Subsequent Actions Return This Page to the Initiating Jurisdiction Page 2 of 2 OMB No. 0970 - 0085 INSTRUCTIONS FOR CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS PURPOSE OF THE FORM : This transmittal form is for use by either the initiating or responding jurisdiction for requesting or providing additional information or services in previously-referred cases. The CSE Transmittal #2 should not be used for making initial referrals, but should only be used for subsequent requests and communication. This form need not be sent when the Notice of Controlling Order form is sent. The CSE Transmittal #2 should be sent to the local entity working the case (rather than the State's central registry) unless the local entity working the case is unknown. HEADING/CAPTION (Pages 1 & 2) : The jurisdiction which sends the CSE Transmittal #2 determines the heading. Note that the heading appears on both page 1 of the Child Support Enforcement Transmittal #2 and on page 2, the Acknowledgment page.  Identify the petitioner and respondent in the appropriate spaces.  Check the appropriate space to identify the type of case: IV-D Non Public Assistance; IV-D Non Public Assistance Medicaid (indicate whether receiving Full Services or Medical Services Only); IV-D Public Assistance; IV-E Foster Care; or Non IV-D. IV-D means the case is being worked by the State or local child support enforcement agency (i.e., IV-D agency). Public Assistance means the obligee's family receives IV-A cash payments [IV-A was formerly called Aid to Families with Dependent Children (AFDC) and is now called Temporary Family Assistance]. A IV-D Non Public Assistance Medicaid case is a case where the obligee's family receives Medicaid but does not receive Public Assistance (IV-A cash payments).  In the space marked "To:", list the name and address (street, city, State, and zip code) of the court or agency where you are sending the CSE Transmittal #2. Once an initial referral in a IV-D case has been made to the responding State's central registry (using CSE Transmittal #1), subsequent communication can occur with the local agency/court/jurisdiction that is actually working the case (using CSE Transmittal #2).  In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction's FIPS code, State, IV-D case number, and docket number. Under "docket number", you may enter the docket number, cause number, or any other appropriate reference number that the responding State may use to identify the case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction.  In the space marked "From:", list a contact person, agency name, address (street, city, State, zip code), phone number (including extension), fax number, and Internet address.  In the appropriate spaces, enter the Initiating jurisdiction's FIPS code, State, IV-D case number, and docket number. Under "docket number", you may enter the docket number, cause number, or any other appropriate reference number which the initiating tribunal or agency has assigned to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services.  In the space marked "Send Payments To:" enter the address to which payments should be sent, if the address is diferent from the agency address provided on the form in the space above. Specify the case identifer if you want the responding jurisdiction to use an identifer other than the initiating IV-D case number when Instructions for Child Support Enforcement Transmittal #2-Subsequent Actions--Page 1 remitting payments.  In the appropriate spaces, enter the FIPS code and State where payments should be sent.  If funds can be transmitted electronically via Electronic Funds Transfer (EFT), enter the bank account number under "Bank Account" and the bank routing code under "Routing Code".  Check the appropriate box to indicate whether the initiating jurisdiction uses the Uniform Reciprocal Enforcement of Support Act (URESA) or the Uniform Interstate Family Support Act (UIFSA).  In the appropriate space, enter the State which you believe has continuing exclusive jurisdiction (CEJ), if known. Under UIFSA, a State that issues a child support order maintains CEJ as long as the obligor, obligee, or child(ren) reside in that State, or until each party fles written consent allowing another State to assume CEJ. If there are multiple orders governing the same obligor, obligee, and child(ren), UIFSA contains rules for determining which order is controlling. The tribunal that issued the controlling order has CEJ as long as the conditions for CEJ are met. CEJ means the authority to modify the order. SECTION I (page 1), ACTION : Check the appropriate box(es) to indicate which actions are requested or what information is being provided. Multiple boxes may be checked, as appropriate.  Check item 1 "Status Request" if you are asking for a status update. Describe the request in Section II.  Check item 2 "Status Update" if you are providing a status update. Provide the update in Section II.  Check item 3 "Notice of Hearing" if you are providing notice of an upcoming hearing. Provide dates and other information in Section II.  Check item 4 "Notice of Case Forwarding" if you are providing notice that you have forwarded a misdirected case to the appropriate jurisdiction. Explain in Section II.  Check item 5 "Document Filed" if you are providing notice that a document has been fled. Explain in Section II.  Check item 6 "Order Issued/Confrmed" if you are providing notice that an order has been issued or confrmed. Attach a copy of the order.  Check item 7 "Notice of Arrearage Reconciliation/Determination of Sum-Certain" if you are providing notice of an arrearage reconciliation or determination of sum-certain. Attach any calculations or worksheets used.  Check item 8 "Change of Payee/Redirection of Payment" to request a change of payee or redirection of payment. Describe your request in Section II "Additional Information". "Change of Payee" is an administrative action used when the person or agency entitled to receive funds has changed. It may occur with a change in Public Assistance or Foster Care status or a change in custody. "Redirection of Payment" is an administrative action used when the custodian has moved. In some States a court action may be required if the custodian's move compels transfer of documents or funds to another jurisdiction. Instructions for Child Support Enforcement Transmittal #2-Subsequent Actions--Page 2  Check item 9 "Other" if you are requesting a service or providing information other than the types listed. Describe the service or information on the blank lines.  Check the box beside "Please Return the Acknowledgment Attached" if an acknowledgment is needed. SECTION II (page 1), ADDITIONAL INFORMATION : In this section, provide additional information which may be useful. At the bottom of page 1, provide a specifc worker's name, a direct telephone number (with extension if necessary) and fax number to expedite communications between jurisdictions. PAGE 2, ACKNOWLEDGMENT : When a jurisdiction sends a CSE Transmittal #2 to another jurisdiction, it should include Page 2 Acknowledgment only if the jurisdiction is requesting information or action. If the jurisdiction is sending the Transmittal #2 to provide notice or information, Page 2 Acknowledgment is not needed. Upon receiving a request for action or information on a CSE Transmittal #2, the receiving State completes the Acknowledgments section of page 2. The Acknowledgment can be used to provide any information requested on the CSE Transmittal #2 or to indicate when (how many days or on what date) the requested information will be provided. The jurisdiction sending the Acknowledgment must indicate where the case has been referred for action, and the name, telephone and fax number of a contact person. ******************************************* The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 45 C.F.R. § 303.7 of the child support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 C.F.R. § 303.7. This information is subject to State and Federal confdentiality requirements; however, the information will be fled with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Instructions for Child Support Enforcement Transmittal #2-Subsequent Actions--Page 3