Fill and Sign the Child Support Unstructured Form Sample Florida

Section I. Case Processing Actions: (Provide additional i nformation in section III or as an attachment as appropriate .) Providing : 1. [ ] Status update 8. [ ] Arrears balance and/or accrued i nterest (affidavit of arrears) 2. [ ] Notice of h earing 9. [ ] Notice of health care coverage c hange (see s ection Ill or attachment) 3. [ ] Notice of case f orwarding 10 .[ ] Notice of case receiving tax refund o ffset from federal c ollection 4. [ ] Document f iled and enforcement p rogram 5. [ ] Order i ssued 11.[ ] Nondisclosure finding/a ffidavit 6. [ ] Arrears calculation (month by month) 12.[ ] Other 7 . [ ] Payment history (provide details under section III) Requesting: 13 . [ ] Status update 14 . [ ] Arrears balance and/or accrued Interest (a ffidavit of arrears) 15 . [ ] Payment history 16. [ ] Arrears calculation (month by month) 17. [ ] Administrative review for contested debt certification in the federal collection and enforcement program 18 . [ ] Other (List and describe in section III.) Please return the requested i nformation. CHILD SU PPORT ENFORCEMENT TRANSMITTAL #2 – SUBSEQUENT ACTIONS The information on this form may be disclosed as authorized by law. If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution, or copying of this form or its contents is strictly prohibited. [ ] Child Support Agency Confidential Information Form Attached Petitioner: Legal Name (first, middle, last, suffix) IV-D Case: [ ] TANF Tribal Affiliation (if applicable) [ ] IV -E Foster Care File Stamp [ ] Medicaid Only Respondent: Legal Name (first, middle, last, suffix) [ ] Former Assistance [ ] Never Assistance Tribal Affiliation (if applicable) Responding Locator Code: ___________ State ___________ To: (Agency Name and Address) Responding IV-D Case Identifier : _______________________________ Responding Tribunal Number: _______________________________ Initiating Locator Code: ___________ State ____________ From: (Agency Name and Address) Initiating IV-D Case Identifier: _______________________________ Initiating Tribunal Number: _______________________________ Payment Locator Code: ___________ State _____________ NOTE: [ ] Nondisclosure Finding/Affidavit attached [ ] This form sent through EDE [ ] This request or information sent through CSENet _________________________________________________________________________________________________________________________ Chil d Support Enforcement Transmittal #2 – Subsequent Actions OMB 0970 – 0085 Expiration Date: 12/31/2019 Page 1 of 2 CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 – SUBSEQUENT ACTIONS , PAGE 2 Section II. Intergovernmental Closure Actions: From Initiating Agency: 1. [ ] The initiating agency has closed its IV -D intergovernmental case because ________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________ _________ _______________________________________________________________________________________________________ _______________________________________________ . Proceed with closure of your responding IV-D intergovernmental case. 2. [ ] Close the responding agency’s IV-D intergovernmental case and stop income withholding, if applicable. We are keeping our IV -D case open and your agency’s intergovernmental services are no longer needed. From Responding Agency: 3. [ ] The responding agency has closed its IV-D intergovernmental case at your request. 4. [ ] The responding agency intends to close its IV -D intergovernmental case on ___________________ (mm/dd/yyyy) because your agency failed to provide_________________________________________________ _____________________________ ______________________________________________________________________________________________________ _ _________________________________________________________________________________________________ ____ __ _________________________________________________________________ ______________________________________ . 5. [ ] The responding agency has closed its IV-D int ergovernmental case because your agency failed to respond to the 60 -day notice dated _________________ (mm/dd/yyyy) . Section III. Other Pertinent Information: ( ) Date Contact person (first, middle, last , suffix) Direct t elephone number and extension Fax: ( ) E-mail: Encryption Requirements: When communicating this form through electronic transmission, precautions mu st be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Enforcement. Other electronic means, such as encrypted attachments to e -mails may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140 -2). Child Support Enforcement Transmittal #2 – Subsequent Actions Page 2 of 2 INSTRUCTIONS FOR CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS PURPOSE OF THE FORM: Either the initiating or responding IV-D agency may use this transmittal form to request or provide additional information or services in previously -referred IV -D intergovernmental cases. Do not use the CSE Transmittal #2 for making initial referrals . Send the CSE Transmittal #2 to the local entity working the case, unless directed otherwise by the st ate’s central registry or the local entity working the case is unknown. Also, when a n obligor has contested debt certification in the federal collection and enforcement program and requested an administrative review in the order -issuing state, the submitting state that has an intergovernmental case with the order-issuing state should use this form to ask the order -issuing state to provide the arrears balance and explain in section III. To request administrative review in an order -issuing stat e where there is no open intergovernmental case, use CSE Transmittal #3. HEADING/CAPTION : • Check if a Child Support Agency Confidential Information Form is attached. • Identify the petitioner and respondent by full legal name (first, middle, last , suffix), and, if applicable, include the name of the tribe with which the petitioner or respondent is affiliated. • Check the appropriate box to identify the type of IV-D case: TANF, IV -E foster care, Medicaid only , former assistance, or never assistance. • In the space marked “To:”, list the name and address (street, PO Box, city, state, and zip code) of the agency to which you are sending the CSE Transmittal #2. • In the appropriate spaces, enter the responding jurisdiction’s locat or code, state, IV -D case identifier, and, if applicable, tribunal number. • In the space marked “From:”, list the name and address (street, PO Box, city, state, and zip code ) of the agency that is sending the CSE Transmittal #2 . • In the appropriate spaces, enter the initiating jurisdiction’s locat or code, state, IV -D case identifier, and , if applicable, tribunal number. The responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. Under “IV -D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left -justified up to 15 -character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under “tribunal number”, you may ente r the docket number, cause number, or any other appropriate reference number that the responding tribunal may use to identify the case, if known. Tribal IV -D programs may choose to use the federal Intergovernmental forms. However, they are not required to use or accept such forms . If you have any questions, contact the tribal IV -D agency directly using the contact inf ormation on the OCSE website. If this is a tribal IV -D case, note that tribal locator codes uniquely identify tribal cases with “9” in the first position, 0 (zero) in the second position, and then a 3-character tribal code defined by the Bureau of Indian Affairs (BIA). Italicized text that appears within a “box” refers to policy or provides additional information. TANF means the obligee’s family is currently receiving IV -A cash payments. A Medicaid only case is a case in which the obligee’s family receives Medicaid but does not receive TANF. A former assistance case might be a case for state arrears only or for a family that previously received TANF, but is not doing so at this time. For a n address outside the United States, be sure to include the foreign country and postal code . Instructions for Child Support Enforcement Transmittal #2 – Subsequent Actions Page 1 of 4 • Enter the payment locat or code and state to which payments should be sent. In the “ NOTE:” section, check any of the following that apply: • Non disclosure Finding/Affidavit attached – If there is a finding prohibiting disclosure of a party’s or child(ren)’s address/identifying information or an affidavit alleging that disclosure of such i nformation would result in risk of harm, check the box for “Nondisclosure Finding/Affidavit attached ” and attach a copy of the finding/affidavit in accordance with section 312 of UIFSA. If there is a finding/affidavit prohibiting disclosure, the information must be sealed and may not be disclosed to the other party or the public. You may provide the address of the IV -D agency as a substitute address for the protected party . • This form sent through EDE – Check if this form was sent through the Electronic Document Exchange (EDE). • This request or information s ent through CSENet – Check if this request or information was sent through CSENet. S ection I. C ase Processing Actions : Check the appropriate box(es) to indicate what information is being provided or which actions are requested. Multiple boxes may be checked, as appropriate . Additional i nformation is provide in section III or as an attachment as appropriate . Providing: • Check item 1 “Status u pdate” if you are providing a n update of the case status . Provide the update in section III. • Check item 2 “Notice of hearing” if you are providing notice of an upcoming hearing. Provide the date, time, and other relevant information in section III. • Check item 3 “Notice of case forwarding” if you are providing notice that you have forwarded a case to the appropriate jurisdiction. Explain in section III. • Check item 4 “Docum ent filed” if you are providing notice that a document has been filed. Explain in s ection III. • Check item 5 “Order i ssued” if you are providing a copy of the order issued in the case . • Check item 6 “Arrears calculation” if you are providing a month -by -month accounting of payments due and payments made. • Check item 7 “Payment history” if you are providing a history of payments received through the state disbur sement unit (SDU). Provide details in section III. • Check item 8 “Arrears b alance and/or accrued interest” if you are providing the total amount of arrears under the order and/or the interest that has accrued on the arrears. This is also known as an affidavit of arrears. The initiating jurisdiction is the jurisdiction that referred the case to the respondi ng jurisdiction for services. Under “IV- D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Regi stry, which is a left -justified up to 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under “tribunal number”, you may enter the docket number, cause number, or any other appropriate reference number that the initiating tribunal has assign ed to the case. UIFSA requires that the petition or accompanying document s include certain identifying information regarding the parties and child(ren) (e.g. , residential address, social security number) unless a party alleges in an affidavit or a pleading under oath that the health, safety, or liberty of a party or child would be jeopardiz ed by disclosure of such information. In that event, the information mu st be sealed. If a jurisdiction has reason to believe that information should not be released because of saf ety concerns, it should ensure that there is a nondisclosure finding or an allegation in an affidavit or the pleading that d isclosure of identifying information would result in a risk or harm, as provided under section 312 of UIFSA. In addi tion to identifying information included on this form, it may be appropriate to submit certai n financial information under seal. The following options are available for making IV -D reque sts and sending information on IV -D cases: 1. CSENet transactions are the recommended method for making requests or sending information to anoth er state. If CSENet is not listed as an option on the form, then it cannot be used to convey any of the r equests f or information or IV -D requests provided on the form. Supporting documentation should be sent through EDE, whenever possible. If certified copies are needed, hard copies should also be sent by m ail. Mail or fax may also be used for all documents when ED E is not available. 2. If CSENet transactions are not available in your state, EDE is the next preferr ed method for transmitting your request or information. Both your state and the receiving state must be using the EDE applica tion to use this communication method. 3. If the EDE application is not available in your state or the re ceiving state, then mail or fax must be used to communicate your request. Instructions for Child Support Enforcement Transmittal #2 – Subsequent Actions Page 2 of 4 • Check item 9 “Notice of health care coverage change” if you are providing notice that the health care coverage has changed. In section III , as appropriate, provide the health care provider’s name, address, telephone number, policy and ID number, effective date, the name of the party providing coverage, and the name (s) of the child (ren ) covered . • Check item 10 “Notice of case receiving tax refund offset from federal collection and enforcement program” if you are providing notice that the case is receiving a tax refund offset from a federal collection and enforcement program. If checked, the initiating and responding agencies need to take appropriate measures to safeguard t he information. • Check item 11 “Nondisclosure finding/ affidavit” if you are providing a nondisclosure finding/affidavit that was not sent with the original referral (CSE Transmittal #1). • Check item 12 “ Other” if you are providing information other than the types listed. For example , this could include changes in contact details or an affidavit of direct payment amounts received. Describe the information in section III. Requesting : • Check item 13 “Statu s update” if you are requesting a n update of the case status . • Check item 14 “Arrears b alance and/or accrued interest” if you are requesting an affidavit stating the total amount of arrears under the order and/or the interest that has accrued on the arrears. • Check item 15 “Payment history” if you are requesting a history of payments received through the state disbursement u nit (SDU). • Check item 16 “Arrears c alculation” if you are requesting a month -by -month accounting of payments due and payments made. • Check item 17 “Administrative review for contested debt certification in the federal collection and enforcement p rogram” if you are requesting an administrative review for a contested debt certificatio n in the federal collection and enforcement program. When you are the submitting state and have an intergovernmental case with the order -issuing state , and the obligor contests the submittal for offset and requests an administrative review in the order-issuing state, you should use this form to ask the order -issuing state to provide the arrears balance . Explain in section III. • Check item 18 “Other” for an action that is not listed and describe the action requested in section III . S ection II. Intergovernmental Closure Actions: From Initiating Agency: • Check item 1 “The initiating agency has closed its IV -D intergovernmental case because ________.” to inform the responding agency you have closed the case. List the reason for the closure in the space provided. See 45 CFR 303.11(b) for a list of case closure criteria. The responding agency must close its intergovernmental case. • Check item 2 “Close the respondin g agency’s IV-D intergovernmental case and stop income withholding, if applicable. We are keeping our IV -D case open and your agency’s intergovernmental services are no longer needed.” if you want the responding agency to close its IV-D intergovernmental case and stop income withholding. Provide further instructions in section III. From Responding Agency: • Check item 3 “The responding agency has closed its IV-D intergovernmental case at your request.” when the responding agency has closed its IV-D intergovernmental case upon notice from the initiating agency of the initiating state’s IV -D case closure or upon the initiating agency’s request.  Check item 4 “The responding agency intends to close its IV-D intergovernmental case on (mm/dd/yyyy) because your agency failed to provide __________.” if the initiating agency failed to provide requested inform ation necessary to process the case . Since this is a 60 -day notice, as required by federal regulations, the date you list must be at least 60 days in the future. Use the available space to i dentify the requested information or document(s) that the initiating agency failed to provide .  Check item 5 “The responding agency has closed its IV-D intergovernmental case because your agency failed to respond to the 60 -day notice dated (mm/dd/yyyy).” if the initiating agency failed to respond to the 60 -day notice. Provide the date the 60 -day notice was sent ; it must be at least 60 days in the past. S ection III . Other Pertinent Information : In this section provide additional information that may be useful. If the information is related to a previous section, identify the section number and item number. At the bottom of the form, p rovide a specific contact person’s name, a direct telephone number ( including extension if necessary), a fax number , and an e-mail address to expedite communication between jurisdictions. Instructions for Child Support Enforcement Transmittal #2 – Subsequent Actions Page 3 of 4 Encryption Requirements: When communicating this form through electronic transmission, precautions mu st be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal O ffice of Child Support Enforcement. Other electronic means, such as encrypted attachments to e -mails may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 1 40-2 (FIPS PUB 140 -2). The Paperwork Reduction Act of 1995 Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of infor mation unless it displays a currently valid OMB control number. Instructions for Child Support Enforcement Transmittal #2 – Subsequent Actions Page 4 of 4