Registration Statement Form. This is a Alaska form and can be use in Child Support Services Division Statewide.
Tags: Registration Statement, 0970-0085, Alaska Statewide, Child Support Services Division
STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION Please Reply To: CSSD, MS 5 th 550 WEST 7 AVE., SUITE 310 ANCHORAGE, AK 99501-6699 RE: Directions for Completion of Registration Statement Case No: Case Name: v. The Non-Custodial Parent has been located outside the State of Alaska. The enclosed Registration Statement form is required by the other state to enforce or modify your child support order. Please use a ballpoint pen to sign the enclosed form(s) before a Notary Public. Please complete the highlighted sections. I will complete the information in the Case Summary area as well as the information for the other party. *Warning: The information you provide might be released by the state where the other party resides. If the health, safety or liberty of you or your child would be put at risk by disclosure of identifying information, complete the enclosed “Affidavit and Request for Nondisclosure of Identifying Information.” If you have already completed this form and been granted Non-Disclosure there is no need to complete it again. The Registration Statement(s) must be returned to our office within 30 days or: a) We may close your case; or b) Public Assistance will be notified of your unwillingness to cooperate. *If you have any questions, please call me at (907) 269Sincerely, Child Support Specialist I Interstate Initiation Section Enclosures CSSD 04-1740B (Rev 8/15/11) 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 State and County Issuing Order Support Amount/Frequency Date of Last Payment Tribunal Case Number Amount of Arrears $ $ Period of Computation thru Date [ ] 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) Date Employer (Name, Street, City, State, Zip) Aliases, Maiden Name Social Security Number: III. Father Information Full Name (first, middle, last) [ ] Obligor [ ] Obligee Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) Aliases Social Security Number: IV. Caretaker (If Not a Parent) Relationship to Child(ren) Full Name (first, middle, last) [ ] Has legal custody/guardianship of child(ren) Address (Street, City, State, Zip) 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: 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 [ Notary Public, Court/Agency Official and Title ] Records Custodian Commission Expires OMB 0970 – 0085 Expiration Date: 05/31/2014 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.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 non-IV-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. Italicized text that appears within a “box” refers to policy or provides additional information. HEADING/CAPTION: • In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction’s IV-D case identifier, and Tribunal number. Under “IV-D case identifier”, 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 that the responding State may use to identify the case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. • In the appropriate spaces, enter the Initiating jurisdiction’s IV-D case identifier, and tribunal number. Under “IV-D case identifier”, 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 tribunal or agency has assigned to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. 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. If a nondisclosure finding exists, do not enter the mother’s address/identifying information on the form; you may enter a substitute address. Instructions for Registration Statement Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.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 labeled “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. Instructions for Registration Statement Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com