CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS Petitioner: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) IV-D Case: [ [ [ [ [ ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance Non-IV-D Case: [ ] Respondent: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) File Stamp Responding FIPS Code To: (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 Send Payments To: Initiating Tribunal Number (if different from above) Payment FIPS Code State Bank Account Routing Code I. Action 1. [ ] Status Request 7. [ ] Notice of Arrearage Reconciliation/Determination of Sum-Certain 2. [ ] Status Update 8. [ ] Change IV-D Payee of Responding Tribunal Order 3. [ ] Notice of Hearing 9. [ ] Redirect Payment to Obligee State 4. [ ] Notice of Case Forwarding 10. [ ] Other: 5. [ ] Document Filed 6. [ ] Order Issued/Confirmed Please Return the Acknowledgment Attached II. Additional Information [ ] Nondisclosure Finding Attached ______________________ Date FAX : ________________________________________ Initiating Contact Person (first, middle, last) (________)__________________________ Child Support Enforcement Transmittal #2 - Subsequent Actions (________)__________________ Phone Number & Extension E-Mail ______________________________________ OMB 0970 - 0085 Expiration Date: 01/31/2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #2 - SUBSEQUENT ACTIONS Petitioner: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) IV-D Case: [ [ [ [ [ ] TANF ] IV-E Foster Care ] Medicaid Only ] Former Assistance ] Never Assistance Non-IV-D Case: [ ] Respondent: Name (first, middle, last) Social Security Number Tribal Affiliation (if applicable) File Stamp Responding FIPS Code To: (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 Send Payments To: Initiating Tribunal Number (if different from above) Payment FIPS Code State Bank Account Routing Code Return This Form to Initiating State ACKNOWLEDGMENTS [ ] Request Received and No Additional Information is Necessary [ ] Additional Information Needed (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 #2 - Subsequent Actions Return This Page to the Initiating Jurisdiction Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com