Fill and Sign the Locate Data Sheet Use Csenet If Agreement is in Place Form

Locate Data SheetOM B No. 0970 - 0085 Expiration Date: 01/31/2011 Page 1 of 1 [ ] Non Custodial Parent Information[ ] Custodial Parent Information[ ] Possibly Dangerous Full Name (first, middle, last) Social Security Number(s) [ ] Alias [ ] Maiden Name [ ] Mother's Maiden or Father's Name Date of Birth (or approximate year) Place of Birth (City, State, County) Driver's License Number/State Sex Race Distinguishing Marks, Scars, Tattoos, Glasses, Etc. Last Known Address [ ] Residence [ ] Mailing [ ] Confirmed [ ] Confirmed Telephone: Usual Occupation/Professional Licenses Last Known Employer (Name, Full Address, Federal EIN) Date Other Information, Including Assets, Education, Police Record, Public As\ sistance History, Incarceration Facility/Address if using for service of process Employment Wage Qtr Wage Year Attachments: [ ] Photograph [ ] Other Items, e.g., Fingerprints Date Initiating Contact Person (first, middle, last) Phone Number and Extension ( ) ( ) Fax Number E-mail Current Spouse's Name (first, middle, last) Weight Height Eyes Hair Wage Amount Date ( ) Telephone: ( ) LOCATE DATA SHEET - Use CSENet If Agreement Is In Place Petitioner: Name Social Security Number Respondent: Name Social Security Number To: From: (first, middle, last) (first, middle, last) File Stamp (Central Registry or Agency Name and Address) (Contact Person, Agency, Address, Phone, Fax, E-mail) IV-D Case: [ ] TANF [ ] IV-E Foster Care [ ] Medicaid Only [ ] Former Assistance [ ] Never Assistance Non-IV-D Case: [ ] Initiating IV-D Case Number Initiating FIPS Code State Initiating Tribunal Number Locate Data Sheet Page  of 2 INSTRUCTIONS FOR LOCATE DATA SHEET PURPOSE OF THE FORM: The Locate Data Sheet is used by a IV-D agency for requesting locate information (regarding either parent, e\ mployer, wages, assets) from another State. The requesting jurisdiction completes as much of the form as possible wi\ th the information it has.Italicized text that appears within a “box” refers to policy or pr\ ovides additional information. In addition to the more common data elements specified 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. USE CSENET IF AN AGREEMENT IS IN PLACE. Quick Locate. The Locate Data Sheet is used to request “quick locate.” You may send the request directly to the responding State’s Parent Locator Service. “Quick locate” is useful if a State bel\ ieves that a 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 confirm the parent’s location. HEADING/CAPTION: Identify the petitioner and respondent name (first, middle, last) and Social Security Number in the appropriate spaces. Check the appropriate space to identify the type of case: TANF; IV-E Foster Care, Medicaid only; former assistance, never assistance, or Non-IV-D. TANF means the obligee’s family receives IV-A cash payments. A Medicaid only case is a case where the obligee’s family receives Medicaid but does not receive TANF (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 Locate Data Sheet. In the space marked “From:”, list a contact person, agency name, a\ ddress (street, city, State, zip code), phone number (including extension), fax number, and e-mail address. In the appropriate spaces, enter the Initiating jurisdiction’s FIPS code, State, and IV-D case number, and tribunal number. Under “IV-D case number”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified 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 which the initiating tribuna\ l or agency has assigned to the case. The initiating jurisdiction is the jurisdiction that referr\ ed the case to the responding jurisdiction for services. 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(s)”, 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. Enter the party’s “Current Spouse’s Name”, if known. Enter the party’s date of birth or approximate year of birth if exact date is unknown. • • • • • • • • • • • • Locate Data SheetPage 2 of 2 Enter the party’s place of birth, if known. Enter the party’s driver’s license number and State of issuance, if known. Enter the party’s sex as M or F. When listing a party’s race, select from the following: ) White (non-hispanic), 2) Black (non¬hispanic), 3) Hispanic, \ 4) American Indian - Alaskan Native, or 5) Asian - Pacific Islander. Enter the party’s hair and eye color and weight in pounds and height in feet and inches, if known. Enter the party’s distinguishing marks, trying to be as specific as possible to aid in identification. For “Last Known Address” and “Last Known Employer” information, indicate if the information has been confirmed/ verified by the initiating State agency. Indicate the date the information was confirmed. If the information has not been confirmed, provide last known information. Under “Usual Occupation/Professional Licenses”, list any licenses you are aware of the party holding. Under “Other Information” list any additional information that may\ be useful in locating the party. Attach photograph or fingerprints if available. Under “Employment” list information obtained from the State agency (SESA). Indicate the quarter and year that the information was reported to the SESA as well as the wage amount. If the individual is incarcerated and service of process is being requested, provide the name\ and address of the facility. At the bottom of the form, provide a specific worker’s name, a direct telephone number (with extension if necessary), fax number and e-mail address to expedite communication between jurisdic\ tions. The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 42 U.S.C. 651 et seq. and 45 CFR 303.7 of the child support enforcement program. Standard forms are designed to provide unif\ ormity and standardization for interstate case processing. Public reporting burden for this collection of informat\ ion is estimated to average under half an hour per response. The responses to this collection are mandatory in accordance with the ab\ ove statute and regulation. 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 . • • • • • • • • • •