Form 1 Transmittal 1 Acknowledgment

CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST

ACKNOWLEDGMENT

The information on this form may be disclosed 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.

Petitioner: Legal Name (first, middle, last, suffix)

Tribal Affiliation (if applicable)

File Stamp

Respondent: Legal Name (first, middle, last, suffix)

Tribal Affiliation (if applicable)

To: (Agency Name and Address)

Initiating Locator Code:

__________

State

_______________

Initiating IV-D Case Identifier:

_________________________________

Initiating Tribunal Number:

_________________________________

From: (Agency Name and Address)

Responding Locator Code:

___________

State

________________

Responding IV-D Case Identifier:

__________________________________

Responding Tribunal Number:

__________________________________

NOTE:

[ ] This form sent through EDE

[ ] This request or information sent through CSENet

ACKNOWLEDGMENT:

[ ] Request received and no additional information is necessary

[ ] Additional information needed

[ ] Personal Information Form for UIFSA § 311

[ ] Arrears statement/payment history

[ ] Child Support Agency Confidential Information Form

[ ] Support order(s) [ ] Certified Order [ ] Copy of Order

[ ] Uniform Support Petition

[ ] Acknowledgment of parentage

[ ] General Testimony

[ ] Birth certificate/birth record

[ ] Letter of Transmittal Requesting Registration

[ ] Nondisclosure finding/affidavit

[ ] Declaration in Support of Establishing Parentage

[ ] Other (See Remarks)

[ ] Responding jurisdiction will proceed with administrative enforcement of the order without registration

[ ] Remarks/response

[ ] Your case has been forwarded for action to:

Name of Worker (first, middle, last, suffix):

_________________________________________________________________________

Agency name:

_____________________________________________________________________________________

Address:

_________________________________________________________________________________________

Locator code: _____________________

Direct Telephone number and Extension:

_______________________________________________________________

Fax:

( )

E-mail:

( )

Date

Person completing form (first, middle, last, suffix)

Direct Telephone Number and Extension

Fax:

( )

E-mail:

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 emails may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

INSTRUCTIONS FOR CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - ACKNOWLEDGMENT

PURPOSE OF THE FORM:

The purpose of the form is to inform the initiating jurisdiction of the responding jurisdiction’s receipt of Transmittal #1 and request any additional information or forms that are needed to take further action on the case. You may acknowledge receipt of the Transmittal #1 via CSENet or by returning the separate Transmittal #1 Acknowledgment form.

The information on this form may be disclosed 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.

Italicized text that appears within a “box” refers to policy or provides additional information.

For an address outside the United States, be sure to include the foreign country and postal code.

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.

If this is a tribal IV-D case, note that tribal locator codes uniquely identify tribal cases with “9” 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).

HEADING/CAPTION:

• Identify the petitioner and respondent by full legal name (first, middle, last, suffix) and, if applicable, include the name of the tribe with which the petitioner or respondent is affiliated.

• In the space marked “To:”, list the name and address (street, PO Box, city, state, and zip code) of the initiating agency to which you are sending the CSE Transmittal #1 - Acknowledgment.

• In the appropriate spaces, enter the initiating jurisdiction’s locator code, state, IV-D case identifier, and, if applicable, tribunal number.

The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. Under “IV-D case identifier”, 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 “tribunal number”, you may enter the docket number, cause number, or any other appropriate reference number that the initiating tribunal has assigned to the case.

• In the space marked “From:”, list the name and address (street, PO Box, city, state, and zip code) of the responding agency.

• In the appropriate spaces, enter the responding jurisdiction’s locator code, state, and IV-D case identifier, and, if applicable, tribunal number.

The responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. Under “IV-D case identifier”, 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 “tribunal number”, you may enter the docket number, cause number, or any other appropriate reference number that the responding tribunal may use to identify the case, if known.

In the “NOTE:” section, check any of the following that apply:

• This form sent through EDE – Check if this form was sent through the Electronic Document Exchange (EDE).

• This request or information sent through CSENet – Check if this request or information was sent through CSENet.

CSENet and EDE transactions are the recommended methods 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 or information provided on the form.

Supporting documentation should be sent through EDE, whenever possible.

ACKNOWLEDGMENT: Return this form to the initiating jurisdiction

The responding jurisdiction completes the Acknowledgment and returns it to the initiating jurisdiction. Select the appropriate response(s) below.

• Request received and no additional information is necessary - Check this box if no additional information or documentation is needed to process the case.

• Additional information needed - Check this box if additional information or forms are needed to process the case. Check the form(s) that are needed to process the case. Indicate whether any requested arrears statement/payment history or support order(s) should be certified or a copy.

• Responding jurisdiction will proceed with administrative enforcement of the order without registration - Check this box to inform the initiating jurisdiction if the responding state agency is pursuing administrative enforcement of the order absent registration.  Section 507(b) of UIFSA states that the responding state agency shall consider and, if appropriate, use any administrative enforcement procedures authorized under its law to enforce an order. 

• Remarks/response - Check this box if additional information is being provided to the initiating agency.

• Your case has been forwarded for action to - Check this box to identify the case worker to whom the case has been forwarded and enter the following information: worker name, agency name, address and locator code, direct telephone number (with extension if necessary), fax number, and e-mail address.

• At the bottom of the page, provide the date the form is completed, the name of the person completing the form, a direct telephone number (including extension if necessary), a fax number, and an e-mail address to expedite communication between jurisdictions.

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).

The Paperwork Reduction Act of 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 0.06 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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.

Child Support Enforcement Transmittal #1 – Acknowledgment OMB 0970 – 0085 Expiration Date: 12/31/2019 Page 1 of 2