REGISTRATION STATEMENT Responding IV-D Case No. Initiating IV-D Case No. Responding Tribunal No. Initiating Tribunal No. Action: [ ] Register for Enforcement [ ] Register for Modification I. Case Summary (Background of this Matter: Court / Administrative Actions) Date of Support Order State and County Issuing Order Support Amount/Frequency $ Date of Last Payment [ ] Tribunal Has Determined This to Be Controlling Order II. Mother Information Full Name (First, Middle, Last) [ Tribunal Case No. Amount of Arrears $ [ Period of Computation ________________ thru ______________ Date Date ] Only Order ] Obligor [ ] Obligee Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) ] Obligor [ ] Obligee Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) Aliases, Maiden Name SSN: III. Father Information Full Name (First, Middle, Last) [ Aliases SSN: IV. Caretaker (If Not a Parent) Full Name (First, Middle, Last) Relationship to Child(ren) _________________________ [ Address (Street, City, State, Zip) ] Has legal custody/guardianship of child(ren) Aliases SSN: V. Additional Case Information [ ] Nondisclosure Finding Attached This order is registered in the following states: Description and location of any property not exempt from execution: Other: VI. Verification / Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief. __________________________________ Date __________________________________ Sworn to and Signed Before Me This Date, County/State Registration Statement _____________________________________________________________________________ [ ] Party Seeking Registration [ ] Records Custodian ___________________________________________ Notary Public, Court/Agency Official and Title __________________________ ______ Commission Expires OMB No. 0970 - 0085 Expiration Date: 01/31/2008 Page 1 of 1 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR REGISTRATION STATEMENT PURPOSE OF THE FORM: The Registration Statement is completed by the initiating jurisdiction to request registration of an existing order for enforcement and/or modification. The purpose of the form is to refer specific order information to the responding State. This form can be used in IV-D and non-IV-D interstate cases. It should be included with the other appropriate forms and directed to the responding State's central registry. In nonIV-D cases, contact the responding State central registry to determine appropriate procedures. It is important to remember that a separate Registration Statement is needed for each order that the initiating State is requesting be registered by the responding State. HEADING/CAPTION: The initiating jurisdiction adds its IV-D case and tribunal numbers to the heading, at the space available. The responding jurisdiction will add its IV-D case and Tribunal numbers to the heading after receiving the form from the initiating jurisdiction. Under initiating and responding “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. ACTION: Check the appropriate box indicating whether you are registering this order for enforcement or modification. NOTE that registration for enforcement should be accompanied by Transmittal #1. Registration for modification should be accompanied by Transmittal #1, Uniform Support Petition, and General Testimony. SECTION I, CASE SUMMARY Provide complete information for all court/administrative actions regarding support for dependents. Use a separate Registration Statement form for each court/administrative order you are requesting be registered. For the listed order, under "Period of Computation", enter the month, day, and year for both the beginning of the current support obligation and the end date of the computation. 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. The arrears statement/payment history must support this calculation. If this order was determined by a tribunal to be the controlling order, check the appropriate box. If this is the only order, check "Only order". Attach the required number of copies of all pertinent orders that relate to support. You will generally need to attach two copies, one of which is certified, of any support order. NOTE, however, that some responding States may be able to take certain administrative enforcement actions (e.g., interstate income withholding) without having a certified copy of the order, although a regular copy is necessary. SECTION II, 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 and maiden name, and all other information. Provide the name and full address of the mother's employer. If the mother's name does not match with the court or administrative order, explain in Section V. Registration Statement Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com SECTION III, FATHER INFORMATION: This section provides basic information about the child(ren)'s 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. Provide the name and full address of the father's employer. If the father's name does not match with the court or administrative order, explain in Section V. SECTION IV, 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. Indicate whether the caretaker has legal custody/guardianship of child(ren), if known. SECTION V, ADDITIONAL CASE INFORMATION: In this section, provide additional information which may be useful to the responding jurisdiction in working the case, such as a complete listing of all States where the child support order has previously been registered and a description, including the location, of all known property or assets not exempt from execution. In addition to the requested information, use this portion of the form to provide other information which may assist the responding jurisdiction in its efforts to register the order. SECTION VI, VERIFICATION / CERTIFICATION: The Registration Statement may be signed by either the party seeking registration or an authorized IV-D representative/records custodian. Check the appropriate box to indicate who has signed this form. The verification signature requires a notary. ******************************************* 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 uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average under half an hour per response. The responses to this collection are mandatory in accordance with the above 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. 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