Fill and Sign the Locate Data Sheet and Instructions Form

LOCATE DATA SHEET 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. ___________________________________________________ Initiating Jurisdiction [ ] URESA [ ] UIFSA [ ] Non Custodial Parent Information [ ] Custodial Parent Information [ ] Possibly Dangerous Full Name (First, Mid, Last) Social Security Number(s) [ ] Alias [ ] Maiden Name [ ] Mother's Maiden or Father's Name Current Spouse's Name (Fst, M, Lst) Date of Birth (or approximate year) Place of Birth (City, State, County) Driver's License Number/State Sex Race Hair Eyes Height Weight Distinguishing Marks, Scars, Tattoos, Glasses, Etc. Last Known Address - [ ] Residence [ ] Mailing [ ] Confrmed Date _____ Last Known Employer (Name, Full Address, Federal EIN [ ] Confrmed Date _____ Telephone ( )___________________ Usual Occupation/Professional Licenses Other Information, Including Assets, Education, Police Record, Public Assistance History Wage Year_______________ Employment Wage Qtr ________________ Attachments: [ ] Photograph [ ] Other Items, e.g. Fingerprints Wage Amount Locate Data Sheet OMB No. 0970 - 0085 Page 1 of 1 ____________ ____________________ ___________________________________________ (_______)________________________________ _______________________ Date Initiating Contact Person (Print or Type) Telephone Number and Extension ( )__________________ Fax Number Locate Data Sheet OMB No. 0970 - 0085 Page 1 of 1 OMB No. 0970 - 0085 INSTRUCTIONS FOR LOCATE DATA SHEET PURPOSE OF THE FORM : The Locate Data Sheet is used for requesting locate information (regarding the parent, employer, wages, assets) or services from another State. The requesting jurisdiction completes as much of the form as possible with the information it has. In addition to the more common data elements specifed on the Locate Data Sheet, space is provided to note other locate/asset information particular to the case. For example, information on wages, violence potential, military/veteran status, and relatives may prove useful in working a case. In the interest of expediting the locate process, use CSENet whenever possible . Quick Locate. When using the Locate Data Sheet to request "quick locate", do not attach the Locate Data Sheet to a Child Support Enforcement Transmittal. You may send the request directly to the responding State's Parent Locator Service. "Quick locate" is useful if a State believes that a noncustodial parent may be in one of several States, but is unsure of which State. If a State intends to use its long-arm jurisdiction to establish or enforce an order, it may choose to use "quick locate" to confrm the noncustodial parent's location. Using the Locate Data Sheet as Part of an Interstate Referral. Attach the Locate Data Sheet to the Child Support Enforcement Transmittal #1, and send the request to the responding State's central registry. Use of the Child Support Enforcement Transmittal #1 will require the responding State to open a IV-D case and provide services. An interstate referral should be made in cases where a State is relatively sure that the noncustodial parent is in a specifc State. HEADING/CAPTION :   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 or agency where you are sending the Locate Data Sheet.   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.   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 Instructions for Locate Data Sheet--Page 1 number, cause number, or any other appropriate reference number which the initiating tribunal or agency has assigned to the case.   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). BODY OF FORM :   Check the appropriate box to indicate whether the locate information pertains to the "Non Custodial Parent" or "Custodial Parent". Check the box for "Possibly Dangerous" if the party may be dangerous.   Provide as much information about the party as possible.   For "Full Name", enter the party's complete name (First, Middle, Last).   Provide "Social Security Number" if known; this information is vital.   Enter the party's "Alias", "Maiden Name", or "Mother's Maiden or Father's Name" if known and check the appropriate box to identify the type of name provided.   When listing a party's race, select from the following: 1) White (non-hispanic), 2) Black (non-hispanic), 3) Hispanic, 4) American Indian - Alaskan Native, or 5) Asian - Pacifc Islander.   For "Last Known Address" and "Last Known Employer" information, indicate if the information has been confrmed/verifed by the initiating State agency. Indicate the date the information was confrmed. If the information has not been confrmed, provide last known information.   Under "Employment" in the bottom right hand corner, list information obtained from the State Employment Security Agency (SESA). Indicate the quarter and year that the information was reported to the SESA as well as the wage amount.   At the bottom of the form, provide a specifc worker's name, a direct telephone number (with extension if necessary) and fax number to expedite communication between jurisdictions. ****************************************** The Paperwork Reduction Act of 1995 This 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 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 Locate Data Sheet--Page 2