Alaska Department of Revenue Please Reply To: CSSD, MS 5 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 Telephone: (907) 269-6900 FAX: (907) 787-3220 www. childsupport.alaska.gov Child Support Services Division RE: Directions for Completion of Registration Statement Case No: Case Name: The Non-Custodial Parent has been located outside the State of Alaska. In order for us to ask for assistance from the other state, you must complete the attached forms. You must type or use a black ballpoint pen to fill out the highlighted areas of the forms. I will complete the Case Summary and the other party information with the most current information when I receive it back from you. Your signature must be notarized. Free notary services are available in our Customer Service Center, located at 550 W 7th Ave, Anchorage, 3rd floor. Please complete and return the forms within 30 days. If you do not return these forms, we cannot move forward with your case. If you are receiving public assistance we will be required to report your failure to cooperate. The following forms are available to view or print from our website www.childsupport.alaska.gov/Forms/forms.asp · · · Affidavit and Request for Nondisclosure of Identifying Information (form #29) Instructions for Affidavit in Support of Establishing Paternity (form #8A) Registration Statement and instructions (form #12) If you need assistance completing the forms, please contact me at (907) 269-6900 and I can assist you over the phone or an appointment can be set up to help you in our office. Sincerely, Child Support Specialist I Enclosures CSSD 04-1740B (Rev 11/14/12) TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3220 SOUTHEAST: (907) 465-5887 FAIRBANKS: (907) 451-2830 MAT-SU: (907) 357-3550 American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION STATEMENT Responding IV-D Case Identifier Responding Tribunal Number Initiating IV-D Case Identifier Initiating Tribunal Number Action: [ [ ] Register for Enforcement ] Register for Modification I. Case Summary (Background of this Matter: Court / Administrative Actions) Date of Support Order Support Amount/Frequency $ State and County Issuing Order Date of Last Payment Tribunal Case Number Period of Computation thru Date Date Amount of Arrears $ [ ] Tribunal Has Determined This to Be Controlling Order [ ] Only Order II. Mother Information [ ] Obligor [ ] Obligee Full Name Address (Street, City, State, Zip) (first, middle, last) Aliases, Maiden Name Social Security Number: III. Father Information Full Name (first, middle, last) Aliases Social Security Number: IV. Caretaker (If Not a Parent) Full Name (first, middle, last) Aliases Social Security Number: 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: Relationship to Child(ren) Employer (Name, Street, City, State, Zip) [ ] Obligor [ ] Obligee Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) [ ] Has legal custody/guardianship of child(ren) Address (Street, City, State, Zip) 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 [ ] Party Seeking Registration [ ] Records Custodian Sworn to and Signed Before Me This Date, County/State Registration Statement Notary Public, Court/Agency Official and Title Commission Expires OMB 0970 ­ 0085 Expiration Date: 05/31/2014 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com