002 002 CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM FOR IV -D AGENCY USE ONLY 226 DO NOT FILE WITH A TRIBUNAL OR PROVIDE TO THE OTHER PARTY The information on the form may be disclosed only as authorized by law. If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution, or copying of this form or its contents is strictly prohibited. N OTE: 002 [ ] This form sent through EDE002 Section I. Case Information: Initiating jurisdiction name: Responding jurisdiction name: Initiating IV-D case identifier: Responding IV-D case identifier: Initiating tribunal number: Responding tribunal number: Section II. Parent/Caretaker Information: Parent [ ] Obligee or [ ] Obligor Parent [ ] Obligee or [ ] Obligor Legal name (first, middle, last, suffix): Legal name (Child Support Agency Confidential Information Form OMB 0970 226 0085 Expiration Date: Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 002 CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM , P AGE 2002 Caretaker - Obligee (When obligee is not the child(ren)222s parent) Legal name (first, middle, last, suffix): Relationship to child(ren): Gender: [ ] Male [ ] Female [ ] Other Date of birth: SSN: Home telephone: Cell telephone: Work telephone: Home address (street, city, state, zip code): Date address confirmed: Mailing address (street, PO Box, city, state, zip code): Date address confirmed: E-mail: Section III. Child(ren) Information: Child #1 legal name (first, middle, last, suffix): Home address (street, city, state, zip code): SSN: Date of birth: Place of birth (city, county, state): Gender: [ ] Male [ ] Female Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: ) If yes, complete the following: [ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No Parentage was established on (date) in (state). Parentage was established by: [ ] Order [ ] Acknowledgment of Parentage [ ] Adoption [ ] Other: [ ] Parentage was not established. Child Support Agency Confidential Information Form Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM , P AGE 3 Section III. Child(ren) Information (Continued): Ch il d #2 legal n a m e (first, middle, last, suffix): Home address (street, city, state, zip code): SSN : Date of birth : Place of birth (city, county, state): Gender: [ ] Male [ ] Female Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: ) If yes, complete the following: [ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No Parentage was established on (date) in (state). Parentage was established by: [ ] Order [ ] Acknowledg ment of Parentage [ ] Adoption [ ] Other : [ ] Parentage was not established. Child #3 legal name (first, middle, last, suffix): Home address (street, city, state, zip code): SSN : Date of birth : Place of birth (city, county, state): Gender: [ ] Male [ ] Female Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: ) If yes, complete the following: [ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No Parentage was established on (date) in (state). Parentage was established by: [ ] Order [ ] Acknowledgment of Parentage [ ] Adoption [ ] Other: [ ] Parentage was not established. [ ] Additional Child(ren) Information Attached Encryption Requirements: When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Enforcement. Other electronic means, such as encrypted attachments to e-mails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2). Child Support Agency Confidential Information Form Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM PURPOSE OF THE FORM: This form is for Child Support (IV-D) Agency use only and is not to be filed with a tribunal or provided to the other party. The Child Support Agency Confidential Information Form is intended to safeguard the privacy of individuals by providing a means to record their personal identifiable information on a separate document that is not served on the parties or filed with a tribunal. The information contained in the form is governed by federal and state safeguarding and privacy requirements. In the 223NOTE:224 section, check any of the following that apply: 225 This form sent through EDE 226 Check if this form was sent through the Electronic Document Exchange (EDE). Section I. Case Information In the space provided, enter: Initiating jurisdiction name Initiating IV-D case identifier Initiating tribunal number Responding jurisdiction name Responding IV-D case identifier, if known Responding tribunal number, if known Italicized text that appears within a 223box224 refers to policy or provides additional information. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. The responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. Under 223IV-D case identifier224, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified up to 15-character alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase. Under 223tribunal number224, you may enter the docket number, cause number, or any other appropriate reference number that the initiating and responding tribunals have assigned to the case. For a n address outside the United States , be sure to include the foreign country and postal code. The following options are available for making IV-D requests and sending information on IV-D cases: 1. CSENet transactions are the recommended method for making requests or sending information to another state. If CSENet is not listed as an option on the form, then it cannot be used to convey any of the requests for information or IV-D requests provided on the form. Supporting documentation should be sent through EDE, whenever possible. If certified copies are needed, hard copies should also be sent by mail. Mail or fax may also be used for all documents when EDE is not available. 2. If CSENet transactions are not available in your state, EDE is the next preferred method for transmitting your request or information. Both your state and the receiving state must be using the EDE application to use this communication method. 3. If the EDE application is not available in your state or the receiving state, then mail or fax must be used to communicate your request. Tribal IV-D programs may choose to use the federal Intergovernmental forms. However, they are not required to use or accept such forms. If you have any questions, contact the tribal IV-D agency directly using the contact information on the OCSE website. Where forms request a locator code, note that tribal locator codes uniquely identify tribal cases with 2239224 in the first position, 0 (zero) in the second position, and then a 3-character tribal code defined by the Bureau of Indian Affairs (BIA). Child Support Agency Confidential Information Form Instructions Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 Section II. Parent/Caretaker Information: Identify each parent as the obligee or obligor, as appropriate. UIFSA defines obligor to include a person alleged to be a parent. For each parent, enter: 003 Full legal name (first, middle, last, suffix) 003 Relationship to the child(ren) 003 Gender* 003 Date of birth 003 Place of birth (city, county, state or the foreign country of birth) 003 Social Security Number 003 Home telephone number 003 Cell telephone number 003 Work telephon