Child Support Enforcement Transmittal #1 - Initial RequestOMB No. 0970 - 0085 Page 1 of 3 CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST
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)
[ ] Non-IV-D File Stamp
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 different from above) Payment FIPS Code ________ State ____________
Bank Account ____________ Routing Code _______
Initiating Jurisdiction [ ] URESA [ ] UIFSA State with Continuing Exclusive Jurisdiction (CEJ) ____________
I. Action. The Responding Jurisdiction Should Provide All Appropriate Services Including:
1. [ ] Establishment of Paternity 6. [ ] Registration of Foreign Support Order:
2. [ ] Establishment of Order for: A. [ ] For Enforcement Only C. [ ] For Modification
A. [ ] Child Support D. [ ] Medical Coverage B. [ ] For Modification and Enforcement
B. [ ] Spousal Support E. [ ] Other Costs (Use Sec. VII) Requested by: [ ]Obligor [ ]Obligee [ ]State Agency
C. [ ] Support for a Prior Period (Requires Sworn Statement of Arrears)
3. [ ] Enforcement of Responding Tribunal Order 7. [ ] Collection of Arrears
4. [ ] Modification of Responding Tribunal Order 8. [ ] Income Withholding
5. [ ] Change of Payee/Redirection of Payment 9. [ ] Administrative Review for Federal Tax Offset
Please Return the Acknowledgment Attached (3 of 3) 10. [ ] Other __________________
II. Case Summary (Background of this Matter: Court/Administrative Actions)
Date of Support Order State & County Issuing Order Tribunal Case No.
Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation
$ $ ____thru____............................................. [ ] Presumed Controlling Order [ ] Determined Controlling Order
Date of Support OrderState & County Issuing Order Tribunal Case No.
Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation
$ $ ____thru____............................Date
[ ] Presumed Controlling Order [ ] Determined Controlling Order
Date of Support OrderState & County Issuing Order Tribunal Case No.
Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation
$ $ ____thru____............................. [ ] Presumed Controlling Order [ ] Determined Controlling Order
Child Support Enforcement Transmittal #1 - Initial Request Page 2 of 3 CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1- INITIAL REQUEST Initiating IV-D Case No.
III. Mother Information[ ] Obligor [ ] Obligee
Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip)
(First, Middle, Last)
Home Phone ( ) [ ] Address Confirmed ________[ ] Employer Confirmed ______
Date Date
Work Phone ( )
Date/Place of Birth______ ____________ Social Security No._____________
Date Place
IV. Father Information[ ] Obligor [ ] Obligee
Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip)
(First, Middle, Last)
Home Phone ( ) [ ] Address Confirmed ______[ ] Employer Confirmed ______
Date Date
Work Phone ( )
Date/Place of Birth________ _____________ Social Security No.______________
Date Place
V. Caretaker (If Not a Parent)Relationship to Child(ren)______________________________
Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip)
(First, Middle, Last)
Home Phone ( ) [ ] Address Confirmed ______[ ] Employer Confirmed _______
Date Date
Work Phone ( )
Date/Place of Birth_______ ______________ Sex__ Social Security No._____________
Date Place M/F
VI. Dependent Children Information State of Residence
Full Name (First, Middle, Last) Date of Birth Sex Social Security No. for last 6 months
VI. Additional Case Information
[ ] Nondisclosure Finding Attached
VII. Attachments (Supporting Documentation)
[ ] Arrears Statement/Payment History[ ] Support Order(s)
[ ] Uniform Support Petition (3 Copies)[ ] Divorce Decree
[ ] General Testimony/Affidavit[ ] Assignment of Rights
[ ] Affidavit in Support of Establishing Paternity[ ] Description of Real/Personal Property
[ ] Acknowledgment of Parentage[ ] Photograph of Respondent
[ ] Other Documents Relating to Paternity[ ] Other Attachments
_____________ ___________________________ (____)_________________
Date Initiating Contact Person (Print or Type) Telephone Number & Extension
(____)_________________
Fax Number
Child Support Enforcement Transmittal #1 - Initial Request Return This Page to the Initiating Jurisdiction Page 3 of 3 CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST
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)
[ ] Non-IV-D File Stamp
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 different from above) Payment FIPS Code ________ State _____________
Bank Account _____________ Routing Code _______
Initiating Jurisdiction [ ] URESA [ ] UIFSA State with Continuing Exclusive Jurisdiction (CEJ) ____________
ACKNOWLEDGMENTSReturn This Form to Initiating State
[ ] Request Received and No Additional Information is Necessary
[ ] Additional Information Needed
[ ] Arrears Statement/Payment History[ ] Support Order(s)
[ ] Uniform Support Petition[ ] Divorce Decree
[ ] General Testimony/Affidavit[ ] Assignment of Rights
[ ] Affidavit in Support of Establishing Paternity[ ] Description of Real/Personal Property
[ ] Acknowledgment of Parentage[ ] Photograph of Respondent
[ ] Other Documents Relating to Paternity[ ] Other (See Remarks)
[ ] Remarks/Response
[ ] 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
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 1OMB No. 0970 - 0085
INSTRUCTIONS FOR
CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST
PURPOSE OF THE FORM: The CSE Transmittal #1-Initial Request form is a "cover letter" required to
refer IV-D interstate cases to any responding State's central registry. The form can also be used in
non-IV-D cases. It contains basic case information and space for indicating which services are
requested. The form can be used to request administrative or legal action, including establishment of
paternity and/or support obligation, modification, or enforcement. It does not take the place of, and
therefore must be accompanied by, the appropriate standard interstate forms (e.g. Uniform Support
Petition, General Testimony, etc.) and supporting documentation.
HEADING/CAPTION (Pages 1 & 3): The initiating jurisdiction determines the heading. Note that the
heading appears on both page 1 of the Child Support Enforcement Transmittal #1 and on page 3, 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
central registry, court, or agency where you are sending the CSE Transmittal #1. In IV-D cases,
initial referrals must be sent to the responding State's central registry. In non-IV-D cases,
contact the responding State central registry to determine appropriate procedures.
#In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction's FIPS
code, State, IV-D case number, and docket number. The responding FIPS code is not essential
for an initial IV-D referral since you will be sending the case to the responding central registry.
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.
#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.
#In the space marked "Send Payments To:" enter the address to which payments should be
sent, if the address is different from the agency address provided in the space labelled "From".
Specify the case identifier if you want the responding jurisdiction to use an identifier other than
the initiating IV-D case number when remitting payments.
#In the appropriate spaces, enter the FIPS code and State where payments should be sent.
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 2 #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, note 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 files 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.
Multiple actions may be requested, as appropriate.
In IV-D cases, the responding jurisdiction should provide the full range of appropriate services. For
example, even if the initiating IV-D agency only checks box 1 "Establishment of Paternity", the
responding jurisdiction should establish paternity, establish a support order, and enforce the support
order.
#Check item 1 "Establishment of Paternity" to request that paternity be established. In a IV-D
case, ask another State to establish paternity only if use of long-arm jurisdiction is not
appropriate. Be sure to attach an "Affidavit in Support of Establishing Paternity" for each child
whose paternity is at issue.
#Check item 2 "Establishment of Order" to request that an order be established. Indicate the
type of order by checking the appropriate box.
Check item 2A "Child Support" to request the initial establishment of a new child
support order. If the responding State uses UIFSA and an order governing the same
obligor, obligee, and child(ren) already exists, you should generally only request
establishment of a new order if: (1) there is more than one existing order, and (2) the
obligor, obligee, and child have all moved out of the issuing States.
Check item 2B "Spousal Support" to request establishment of a spousal support order.
Do not check this item in a IV-D case; establishment of spousal support is not a IV-D
function. When requesting establishment of spousal support, contact the support
enforcement agency for the appropriate procedure.
Check item 2C "Support for a Prior Period" to request establishment of support for a
prior period. States may establish child support awards covering a prior period, but
such awards must be based on guidelines and take into consideration either the current
earnings and income at the time the order is set, or the obligor's earnings and income
during the prior period. The award of back support is not required under Federal rules
but may be appropriate in accordance with State law. Not all States have authority to
establish support orders for prior periods.
Check item 2D "Medical Coverage" to request establishment of an order that provides
for the provision of medical insurance or other health care coverage. Medical support
must be requested in all IV-D Public Assistance cases, all IV-D Non Public Assistance
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 3Medicaid cases, and in other IV-D Non Public Assistance cases where health coverage is
sought.
Check item 2E "Other Costs" to request an order for other costs such as: costs of the
delivery of the child, other medical costs not covered by insurance, genetic testing, and
attorney's fees. Describe the costs in section VII "Additional Case Information".
#Check item 3 "Enforcement of Responding Tribunal Order" to request enforcement of an
existing order that was issued by the responding tribunal.
If multiple orders governing the same obligor, obligee, and child(ren) exist, do not ask a
responding UIFSA State to prospectively enforce (or modify) an order unless that order
is the "controlling order" that has priority under UIFSA. UIFSA contains rules for
determining which order is recognized when multiple orders exist. Under these rules:
1.The order issued by a tribunal with continuing, exclusive jurisdiction (CEJ) has
priority. An issuing tribunal retains CEJ as long as the issuing State remains the
residence of the obligor, obligee, or child, or until all parties file written consent with
the tribunal allowing another State to assume CEJ.
2.If more than one issuing tribunal would have CEJ, the order issued by the child's
current home State has priority.
3.If more than one tribunal would have CEJ but there is no order in the child's current
home State, the most recently issued order has priority.
4.If no tribunal would have CEJ, the responding State may issue a new support order
and it becomes the CEJ State.
#Check item 4 "Modification of Responding Tribunal Order" to request modification (or review
and adjustment) of an existing order that was issued by the responding tribunal.
Do not request a responding UIFSA State to modify its own order if the obligor, obligee,
and child(ren) have all moved out of that State, or if the parties have filed written
consent with the issuing tribunal in that State allowing another State to modify the
order.
If multiple orders exist, do not ask a responding UIFSA State to modify an order unless
that order is the "controlling order" that has priority under UIFSA. UIFSA contains rules
for determining which order is recognized when multiple orders exist.
Generally, you need to attach a completed General Testimony.
#Check item 5 "Change of Payee/Redirection of Payment" to request a change of payee or
redirection of payment. Describe your request in Section VII "Additional Case 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.
#Check item 6 "Registration of Foreign Support Order" to request registration of a support order.
Orders from one State may be registered in another State, under UIFSA, URESA, or the Uniform
Enforcement of Foreign Judgments Act (UEFJA). Also check item 6A "For Enforcement Only",
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 4item 6B "For Modification and Enforcement" or item 6C "For Modification" to indicate whether
the registration is for enforcement and/or modification. Check either item 6B or 6C if you are
requesting review and adjustment of a foreign order. Check the appropriate box to indicate
whether registration is requested by the obligor, obligee, or state enforcement agency.
To modify another State's order, a responding State must first register the order. To
enforce another State's order, a responding State may have to register the order; UIFSA
allows for administrative enforcement without registration (but requires registration for
other enforcement actions).
When requesting registration, certain information or documents are required. The
requirements for requesting registration depend on whether you are registering the order
under UIFSA, URESA or UEFJA or other law. To request registration of an order under
UIFSA, you must include:
oA letter of transmittal to the tribunal requesting registration for enforcement
and/or modification. The CSE Transmittal #1 serves this function. Check the
appropriate boxes in item 6 of section I to indicate the action requested.
oTwo copies, including one certified copy, of all orders to be registered, including
any modification of an order.
oA sworn statement by the party seeking registration or a certified statement by
the custodian of records showing the amount of any arrearage. At State option,
page 6a of the General Testimony may be used for this purpose. In section VIII
"Attachments", check the first box ("Arrears Statement/Payment History") to
indicate that a sworn statement of arrears is attached.
oThe name of the obligor and, if known: the obligor's address and Social Security
Number; the name and address of the obligor's employer and any other source
of income of the obligor; and a description and the location of property of the
obligor in the responding State not exempt from execution. Space for most of
this information is provided on the CSE Transmittal #1. If you have information
about the obligor's other sources of income or property, include the information
in section VII or an attachment. In section VIII, check the box labelled
"Description of Real/Personal Property" if a description is attached.
oThe name and address of the obligee. Space for this information is provided on
the CSE Transmittal #1.
oIf applicable, the agency or person to whom support payments are to be
remitted. Space for this information is included in the heading of the CSE
Transmittal #1.
In addition, to allow the responding State to establish a IV-D case, you will probably
need to complete all other information on the CSE Transmittal #1, particularly
information regarding the children.
Furthermore, when requesting registration for modification, you generally need to attach
a completed Uniform Support Petition and General Testimony.
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 5Do not ask a responding UIFSA State to modify another State's order unless:
o(1) the child(ren), obligee, and obligor do not live in the State that issued the
order; (2) the party seeking modification does not live in the responding State;
and (3) the responding State has personal jurisdiction over the other party (the
party not requesting modification).
OR
oThe responding State has personal jurisdiction over the obligor, obligee, or
child(ren), and the obligor and obligee have filed written consent in the tribunal
that issued the order providing that the responding State may modify the
support order and assume continuing, exclusive jurisdiction over the order.
If multiple orders governing the same obligor, obligee, and child(ren) exist, do not ask a
responding UIFSA State to prospectively enforce or modify an order unless that order is
the "controlling order" that has priority under UIFSA. UIFSA contains rules for
determining which order is recognized when multiple orders exist.
Generally, the CSE Transmittal #1 is used to send initial case referrals and the CSE
Transmittal #2 is used to send/request additional information or action after the initial
referral. However, since the CSE Transmittal #2 does not contain the necessary
information needed to request registration of a foreign order, you may use the CSE
Transmittal #1 to request registration even in a case that has previously been referred
to the responding jurisdiction. If you are requesting registration in a case that has
previously been referred to the responding jurisdiction, you may send the request
directly to the responding entity working the case rather than to the responding central
registry.
#Check item 7 "Collection of Arrears" to request collection of arrears. You should request
enforcement of arrears under all known orders.
#Check item 8 "Income Withholding" to request interstate income withholding. If the employer's
State uses UIFSA, you may send a withholding order/notice directly to the out-of-State
employer. If you prefer, you may still send the CSE Transmittal #1 to send a request for
withholding in a IV-D case to the IV-D central registry in a responding State. In fact, in a IV-D
case, if the employer's State does not use UIFSA and your State does not have jurisdiction over
the employer under State law, you must send a request, using the CSE Transmittal #1, to the
IV-D central registry in the employer's State. Be sure to specify the amount to be withheld.
Attach a copy of the support order and, if appropriate, a statement of arrears. Attach any
other documentation required by the responding State (see the Interstate Roster and ReferralGuide). In some instances, registration of a foreign income withholding order or underlying
support order may be necessary. To request other enforcement techniques, rather than just
income withholding, check item 3 or item 6, as appropriate.
#Check item 9 "Administrative Review for Federal Tax Offset" to request an administrative
review in the responding State if a Federal income tax refund offset has been challenged.
#Check item 10 "Other" if you are requesting a service other than those listed. Describe the
service on the blank line.
SECTION II (page 1), CASE SUMMARY: Provide complete information for all court/administrative
actions regarding support for dependents. If there are more than three orders, use additional page(s)
or Section VII. For "Period of Computation", enter the month, day, and year for both the beginning
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 6 and ending dates. The information in this section will be used to aid in verifying calculated arrearages
and to assist in determining/verifying which order is controlling and which State has continuing
exclusive jurisdiction.
If you believe a particular order is controlling under UIFSA, check the box beside "Presumed Controlling
Order"; otherwise leave the box blank. If there are multiple orders governing the same obligor, obligee,
and child(ren), UIFSA contains rules for determining which order is controlling. The responding tribunal
will make the final determination regarding which order is controlling.
Attach the required number of copies of all pertinent orders that relate to support. If you are sending
this case to a State that uses UIFSA, you will generally need to attach two copies, one of which is
certified, of any support order. If you are sending this case to a State that uses a version of URESA,
you will generally need to attach three certified copies of any support order. Note, however, that
some responding States may be able to take certain administrative enforcement actions (e.g.,
interstate wage withholding) without having a certified copy of the order, although a regular copy is
necessary.
SECTION III (page 2), MOTHER INFORMATION: This section provides basic information about the
child(ren)'s mother. Check the appropriate box to indicate if the mother is the obligor or obligee.
Provide the mother's full name (first, middle, last) as well as aliases or maiden name, and all other
information. List additional information (i.e., phone number changes, relatives' phone numbers,
multiple employers or assets) in section VII. In cases where the mother is the respondent, the
information can be used for location purposes if necessary. If the mother's address has been
confirmed or verified, check the "Address Confirmed" box and indicate the date the address was
confirmed. If the employer/employer's address has been confirmed or verified, check the "Employer
Confirmed" box and indicate the date the information was confirmed. Verified, current information
expedites processing of any child support case. However, if information cannot be verified, provide
last known information.
SECTION IV (page 2), FATHER INFORMATION: This section provides basic information about the
child(ren)'s father. In a case where paternity has not been established, use this section to provide
information about the alleged father. Check the appropriate box to indicate if the father is the obligor
or obligee. Provide the father's full name (first, middle, last) as well as aliases, and all other
information. List additional information (i.e., phone number changes, relatives' phone numbers,
multiple employers or assets) in section VII. In cases where the father is the respondent, the
information can be used for location purposes if necessary. If the father's address has been confirmed
or verified, check the "Address Confirmed" box and indicate the date the address was confirmed. If
the employer/employer's address has been confirmed or verified, check the "Employer Confirmed" box
and indicate the date the information was confirmed. Verified, current information expedites
processing of any child support case. However, if information cannot be verified, provide last known
information.
SECTION V (page 2), CARETAKER (IF NOT A PARENT): Complete this section only if the child(ren)'s
caretaker is not the child(ren)'s parent. In the space labelled "Relationship to Child(ren)", indicate the
relationship of the caretaker to the child(ren). Provide the caretaker's full name (first, middle, last) as
well as aliases or maiden name, and all other information. Note: if the caretaker does not have a legal
obligation to contribute to a child's support, information regarding the caretaker's employment may be
privileged.
SECTION VI (page 2), DEPENDENT CHILDREN INFORMATION: List all children for whom support is
owed or being sought. For each child, provide full name (first, middle, last), date of birth, sex, Social
Security Number, and State of residence for last 6 months. If additional space is needed, use section
VII.
Instructions for Child Support Enforcement Transmittal #1-Initial Request--Page 7 SECTION VII (page 2), ADDITIONAL CASE INFORMATION: In this section, provide additional
information which may be useful to the responding jurisdiction in working the case, such as pending
action, amounts reported to credit bureaus, or prior attempts of long-arm action. If additional space is
needed, attach page(s).
If there is an order preventing disclosure of a party's or child's address/identifying information, check
the box for "Nondisclosure Finding Attached" and attach a copy of the finding. In accordance with
the finding, do not provide the address/identifying information; you may provide a substitute address.
A nondisclosure finding means a finding that the health, safety, or liberty of a party or child would be
unreasonably put at risk by disclosure of identifying information (e.g., residential address). UIFSA
provides that interstate petitions must include certain identifying information regarding the parties and
child(ren) unless a tribunal (court or agency) makes a nondisclosure finding by ordering that the
address or identifying information not be disclosed. The procedures for obtaining a nondisclosure
finding vary from State to State.
SECTION VIII (page 2), ATTACHMENTS: Check the appropriate box(es) to indicate all documents
attached. For attachments other than those listed, check "Other Attachments" and explain in section
VII.
Attach the required number of copies of all pertinent orders that relate to support. If you are sending
this case to a State that uses UIFSA, you will generally need to attach two copies, one of which is
certified, of any support order. If you are sending this case to a State that uses a version of URESA
you will generally need to attach three certified copies of any support order. Note, however, that
some responding States may be able to take certain administrative enforcement actions (e.g.,
interstate wage withholding) without having a certified copy of the order, although a regular copy is
necessary.
At the bottom of page 2, provide a specific worker's name, a direct telephone number (with extension
if necessary) and fax number to expedite communications between jurisdictions.
PAGE 3, ACKNOWLEDGMENT: The responding jurisdiction completes the Acknowledgments section
of page 3 and returns it to the initiating jurisdiction. The initiating jurisdiction should not include this
form in the initial referral packet. This form is intended to be generated by the responding jurisdiction
in response to its receipt of the transmittal packet from the initiating State. In addition to
acknowledging receipt of the case, the responding jurisdiction may request additional information (a
request for state-specific forms which substantially duplicate or duplicate in part the content or
purpose of the standard interstate forms is not allowed) and/or report back to the initiating jurisdiction
what action/results have occurred (e.g., income withholding begun, arrearage reported to credit
bureau, case closed and reason). The responding jurisdiction 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 1995This information collection is conducted in accordance with 45 CFR 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
CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the
information will be filed 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.
