CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST Petitioner: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) IV-D Case: [ [ [ [ [ Respondent: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) To: ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance File Stamp Non-IV-D Case: [ ] Responding FIPS Code (Agency Name and Address) State Responding IV-D Case Number Responding Tribunal Number From: (Contact Person, Agency, Address, Phone, FAX, E-mail) Initiating FIPS Code State Initiating IV-D Case Number Initiating Tribunal Number (if different from above) Payment FIPS Code State Bank Account Send Payments To: Routing Code I. Action. The Responding Jurisdiction Should Provide All Appropriate Services Including: (Please Return the Acknowledgment Attached) 1. [ ] Establishment of Paternity 2. [ ] Establishment of Order for: A. [ B. [ C. [ D. [ E. [ 3. [ 4. [ 5. [ 6. [ ] ] ] ] ] 7. [ ] Registration of Foreign Support Order(s): A. [ B. [ C. [ D. [ For Enforcement Only For Modification and Enforcement For Modification Only For Tribunal Determination of Controlling Order Including Arrears Reconciliation Requested by: [ ] Obligor [ ] Obligee [ ] State Agency (Requires Sworn Statement of Arrears) Current Child Support, Including Medical Support Retroactive Child Support Medical Support Only Spousal Support Costs and Fees (Use Sec. VII) ] Enforcement of Responding Tribunal Order ] Modification of Responding Tribunal Order ] Change IV-D Payee of Responding Tribunal Order ] Redirect Payment to Obligee State II. Case Summary 8. 9. 10. 11. [ [ [ [ ] ] ] ] ] Collection of Arrears Only ] Income Withholding ] Administrative Review for Federal Tax Refund Offset ] Other (Background of this Matter: Court/Administrative Actions) Date of Support Order Support Amount/Frequency $ State & County or Tribe Issuing Order Date of Last Payment Amount of Arrears $ Tribunal Case Number Period of Computation thru [ ] Tribunal Determined Controlling Order [ ] Presumed Controlling Order Date of Support Order Support Amount/Frequency $ State & County or Tribe Issuing Order Date of Last Payment Amount of Arrears $ Tribunal Case Number Period of Computation thru [ ] Presumed Controlling Order Date of Support Order Support Amount/Frequency $ State & County or Tribe Issuing Order Date of Last Payment Amount of Arrears $ Tribunal Case Number Period of Computation thru [ ] Presumed Controlling Order Child Support Enforcement Transmittal #1 - Initial Request OMB 0970 - 0085 Expiration Date: 01/31/2011 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1- INITIAL REQUEST [ ] Obligor III. Mother Information Full Name (first, middle, last) Initiating IV-D Case Number [ ] Obligee Address Employer/Address (Name, Street, City, State, Zip) (Street, City, State, Zip) Maiden Name, Alias, Former Married Name, Nickname, etc. Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth______________ _________________________________ Social Security Number ______________________ Date Place [ ] Obligor IV. Father Information Full Name (first, middle, last) [ ] Obligee Address Employer/Address (Street, City, State, Zip) (Name, Street, City, State, Zip) Alias, Nickname Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth______________ _________________________________ Social Security Number ______________________ Date V. Caretaker Full Name (first, middle, last) Place Relationship to Child(ren)_________________________________________________ [ ] Has Legal Custody /Guardianship of Child(ren) (copy of order attached) Address Employer/Address (Street, City, State, Zip) (Name, Street, City, State, Zip) Maiden Name, Alias, Former Married Name, Nickname, etc. Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth_____________ __________________________ Sex____ Social Security Number ______________________ Date Place VI. Dependent Children Information Full Legal Name (first, middle, last) M/F City, State, Date of Birth Sex Social Security Number State of Residence __________________ for _______months Born Out of Wedlock [ ] YES VII. Additional Case Information [ ] Additional Case Information Attached VIII. Attachments If established, Paternity Establishment Date __________ [ ] NO [ ] Nondisclosure Finding Attached (Supporting Documentation) [ ] Arrears Statement/Payment History [ ] Notice of Determination of Controlling Order [ ] Uniform Support Petition [ ] Support Order(s) [ ] General Testimony/Affidavit [ ] Divorce Decree [ ] Affidavit in Support of Establishing Paternity [ ] Assignment of Rights [ ] Acknowledgment of Parentage [ ] Description of Real/Personal Property [ ] Other Documents Relating to Paternity [ ] Photograph of Respondent [ ] Other Attachments _____________________ Date FAX: ___________________________________________ (____)__________________ Initiating Contact Person (first, middle, last) (________)_________________________ Child Support Enforcement Transmittal #1 - Initial Request Telephone Number & Extension E-mail______________________ Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST Petitioner: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) IV-D Case: [ [ [ [ [ Respondent: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) To: ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance File Stamp Non-IV-D Case: [ ] Responding FIPS Code (Agency Name and Address) State Responding IV-D Case Number Responding Tribunal Number From: (Contact Person, Agency, Address, Phone, FAX, E-mail) Initiating FIPS Code State Initiating IV-D Case Number Initiating Tribunal Number Payment FIPS Code (if different from above) ACKNOWLEDGMENTS [ ] [ ] State Bank Account Send Payments To: Routing Code Return This Form to Initiating State Request Received and No Additional Information is Necessary Additional Information Needed [ ] Arrears Statement/Payment History [ ] Support Order(s) [ ] Uniform Support Petition [ ] Divorce Decree [ ] General Testimony/Affidavit [ ] Assignment of Rights [ ] Affidavit in Support of Establishing Paternity [ ] Description of Real/Personal Property [ ] Acknowledgment of Parentage [ ] Photograph of Respondent [ ] Other Documents Relating to Paternity [ ] Other (See Remarks) [ ] Remarks/Response [ ] Your Case has been Forwarded for Action to: Name of Worker (first, middle, last) Agency Name Address, FIPS Code Phone & Extension FAX Date FAX :( ) Person Completing Form (first, middle, last) Telephone Number & Extension E-mail: Child Support Enforcement Transmittal #1-Initial Request Return This Page to the Initiating Jurisdiction Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com