CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 – INITIAL REQUEST___________ Petitioner IV-D Non Public Assistance IV-D Non PA Medicaid Full Services Respondent Medical Services Only IV-D Public Assistance IV-E Foster Care (IV-D Case) Non-IV-D File Stamp To: (Agency/Tribunal Name and Address) Responding FIPS Code State Responding IV-D Case No. Responding Docket No. From: (Contact Person, Agency, Address, Phone, Fax, Internet ) Initiating FIPS Code State Initiating IV-D Case No. Initiating Docket No. Send Payments To: (If different from above) Payment FIPS Code State Bank Account Routing Code Initiating Jurisdiction URESA UIFSA State with Continuing Exclusive Jurisdiction (CEJ) I. Action. The responding Jurisdiction Should Provide All Appropriate Services Including: 1. Establishment of Paternity 6. Registration of Foreign Support Order: 2. C. Establishment of Order for: A. Enforcement Only For Modification For Modification A. Child Support D. Medical Coverage B. E. Other Costs (Use Sec. VII) Requested by: and Enforcement B. Obligee C. Spousal Support Obligor State Agency Support for a Prior Period (Requires Sworn Statement of Arrears) 3. Enforcement of Responding Tribunal Order 7. Collection of Arrears American LegalNet, Inc. www.FormsWorkflow.com 4. Modification of Responding Tribunal Order 8. Administrative Review for Federal Tax Offset 5. Change of Payee/Redirection of Payment II. Case Summary (Background of this Matter: Court/Administrative Actions) Date of Support Order State & County Issuing Order Case No. Support Amount/Frequency Computation $ Presumed Controlling Order Date of Last Payment Amount of Arrears $ State & County Issuing Order Support Amount/Frequency Computation $ Date of Last Payment thru Tribunal Amount of Arrears $ Period of thru Determined Controlling Order Date of Support Order Case No. State & County Issuing Order Support Amount/Frequency Computation $ Date of Last Payment Presumed Controlling Order Period of Determined Controlling Order Date of Support Order Case No. Presumed Controlling Order Tribunal Tribunal Amount of Arrears $ Period of thru Determined Controlling Order Child Support Enforcement Transmittal #1 – Initial Request Page 1 of 3 FSA-200-1 (Rev. 9-97) Previous edition may be used. OMB No. 0970 – 0085 American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 – INITIAL REQUEST___Initiating IV-D Case No., Page 2______________ III. Mother Information Obligor Full Name and Aliases Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Home Phone ( ) Employed Confirmed Address Confirmed Date Date Work Phone ( ) Date/Place of Birth Social Security No. Date IV. Father Information Place Obligor Full Name and Aliases Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Home Phone ( ) Employed Confirmed Address Confirmed Date Date Work Phone ( ) Date/Place of Birth Social Security No. Date Place V. Caretaker Information (If Not a Parent) Relationship to Child(ren) Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Home Phone ( ) Employed Confirmed Address Confirmed Date Date Work Phone ( ) Date/Place of Birth No. Sex Date VI. Dependent Children Information Full Name (First, Middle Last) Security No. Place Social Security M/F State of Date of Birth Sex for last 6 months Social American LegalNet, Inc. www.FormsWorkflow.com VII. Additional Case Information VIII. Attachments (Supporting Documentation) Arrears Statement/Payment History Order(s) Uniform Support Petition (3 copies) Decree General Testimony/Affidavit of Rights Affidavit in Support of Establishing Paternity of Real/Personal Property Acknowledgment of Parentage of Respondent Other Documents Relating to Paternity Support Divorce Assignment Description Photograph Other Attachments ( Date ) Initiating Contact Person (Print or Type) Telephone Number & Extension ( ) Fax Number Child Support Enforcement Transmittal #1 – Initial Request Page 2 of 3 FSA-200-1 (Rev. 9-97) Previous edition may be used. OMB No. 0970 – 0085 American LegalNet, Inc. www.FormsWorkflow.com REGISTRATION STATEMENT Responding IV-D Case No. Initiating IV-D Case No. Responding Docket No. Initiating Docket No. 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 No. Amount of Arrears Period of Computati $ thru Date II. Mother Information Full Name and Aliases Date Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) SSN: III. Father Information Obligor Full Name and Aliases Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) SSN: IV. Caretaker Information (If Not a Parent) Full Name and Aliases Relationship to Child(ren) Address (Street, City, State, Zip) SSN: V. Additional Case Information This order is registered in the following states: Description and location of any property not exempt from execution: Other: American LegalNet, Inc. www.FormsWorkflow.com 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 t o and Signed Before Me This Date, County/State FSA -207 Registration Statement (Rev. 1-99) Party seeking Registration Records Custodian Notary Public, Court/Agency Official and Title Commission Expi OMB No. 0970-0085 American LegalNet, Inc. www.FormsWorkflow.com