LOCATE DATA SHEET Petitioner IV-D Non Public Assistance IV-D Non PA Medicaid Full Services Medical Services Only Respondent IV-D Public Assistance IV-E Foster Care (IV-D Caste) Non-IV-D File Stamp To: (Agency Name and Address) Responding FIPS Code _________________ State __________________ Responding IV-D Cases No. _____________________________________ Responding Docket No. _________________________________________ From: (Contact Person, Agency, Address, Phone, Fax, Internet) Initiating FIPS Code No. ________________ State ____________________ Initiating IV-D Cases No. _________________________________________ Initiating Docket No. ____________________________________________ Initiating Jurisdiction Non Custodial Parent Information Race Maiden Name Hair Last Known Address Possibly Dangerous Social Security Number(s) Mother’s Maiden or Father’s Name Eyes Current Spouse’s Name (Fst, M, Lst) Place of Birth (City, State, Country) Date of Birth (or approximate Year) Sex UIFSA Custodial Parent Information Full Name (First, Mid, Last) Alias URESA Driver’s License Number/ State Height Residence Weight Distinguishing Marks, Scars, Tattoos, Glasses, Etc., Mailing Confirmed Date___________ Telephone: _____ _____________ Usual Occupation/Professional Licenses Confirmed Date___________ Last Known Employer (Name, Full Address, Federal EIN) Telephone: _____ _____________ Other Information, Including Assets, Education, Police Record, Public Assistance History Employment Wage Qtr ______________ Wage Year_________________ Attachments: Photograph Other Items, e.g. Fingerprints ____________________ _____________________________________ Date Intiating Contact Person (Print or Type) Wage Amount ________ ________________________ Telephone Number and Extension ________ ________________________ Fax Number Locate Date Sheet OMB No.0970 – 0085 Page 1 of 1 American LegalNet, Inc. www.USCourtForms.com 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 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. In the interest of expediting the locate process, use CSE Net 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 on enforce an order, it may choose to use “quick locate” to confirm 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 specific 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 (ie., 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 responding State may use to identity the case, if known. In the space market “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. Instruction for Locate Data Sheet … Page 1 American LegalNet, Inc. www.USCourtForms.com 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 (nonhispanic), 3) Hispanic, 4) American Indian – Alaskan Native, or 5) Asian – Pacific Islander. 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 “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 specific worker’s name, a correct telephone number (with extension if necessary) and fax number to expedite communication between jurisdictions. ***************************************** The Paper work 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 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. Instruction for Locate Date Sheet ... Page 2 American LegalNet, Inc. www.USCourtForms.com