1 Personal Information Form

PERSONAL INFORMATION FORM FOR UIFSA § 311 – TO BE FILED WITH A TRIBUNAL
☐ Nondisclosure finding/affidavit attached
THIS FORM CONTAINS SENSITIVE INFORMATION – DO NOT FILE THIS FORM IN A PUBLIC ACCESS FILE
The information on this form is filed with the petition or pleading and may be disclosed to the parties in the case,
unless accompanied by a nondisclosure finding/affidavit.
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.
NOTE:
[ ] This form sent through EDE
Section 1. 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 2. Parent/Caretaker Information:
Parent [ ] Obligee or [ ] Obligor		Parent [ ] Obligee or [ ] Obligor
Legal name (first, middle, last, suffix):		Legal name (first, middle, last, suffix):
SSN:		SSN:
Home address (street, city, state, zip):		Home address (street, city, state, zip code):
Caretaker - Obligee (When obligee is not the child(ren)’s parent)
Legal name (first, middle, last, suffix):
SSN:
Home address (street, city, state, zip code):
Section 3. Child(ren) Information:
Child #1 legal name (first, middle, last, suffix):
Child's address (street, city, state, zip code):
The child began residing in ___________________ (state) on _____________________ (month/year).
Child’s SSN:		Child’s date of birth:
Gender: [ ] Male [ ] Female
Child #2 legal name (first, middle, last, suffix):
Child's address (street, city, state, zip code):
The child began residing in ___________________ (state) on _____________________ (month/year).
Child’s SSN:	Child’s date of birth:
Gender: [ ] Male [ ] Female

Child #3 legal name (first, middle, last, suffix):
Child's address (street, city, state, zip code):
The child began residing in ___________________ (state) on _____________________ (month/year).
Child’s SSN:	Child’s date of birth:
Gender: [ ] Male [ ] Female

[ ] 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 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 PERSONAL INFORMATION FORM FOR UIFSA § 311

to be filed With A Tribunal

PURPOSE OF THE FORM:

The Personal Information Form for UIFSA § 311 is intended to safeguard the privacy of individuals by providing a means to record required UIFSA personal information on a separate document rather than requiring it to appear on all of the forms needed to process their case. For those states where tribunal records are open to the general public, this disclaimer indicates that the form should be protected from public view in a manner and to an extent authorized by state law and tribunal rules. This form must be included with all petitions to establish parentage and/or a child support order or to register and modify a child support order. The information on this form must be filed with the tribunal, but should not be filed in a public access file.

Nondisclosure Finding/Affidavit attached - If there is a finding prohibiting disclosure of a party’s or child(ren)’s address/identifying information or an affidavit alleging that disclosure of such information would result in risk of harm, check the box for “Nondisclosure Finding/Affidavit attached” and attach a copy of the finding/affidavit in accordance with section 312 of UIFSA. If there is a finding/affidavit prohibiting disclosure, the information must be sealed and may not be disclosed to the other party or the public. You may provide the address of the IV-D agency as a substitute address for the protected party.

THIS FORM CONTAINS SENSITIVE INFORMATION – DO NOT FILE THIS FORM IN A PUBLIC ACCESS FILE.

This form includes information that may pose a significant risk to an individual if made available in a public forum or inappropriately disclosed. This form is filed with the petition or pleading, but should not be filed or included in a record available to the general public. The information on this form may be disclosed to the parties in the case, unless accompanied by a nondisclosure finding/affidavit.

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.

Where forms request a locator code, 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).

UIFSA requires that the petition or accompanying documents include certain identifying information regarding the parties and child(ren) (e.g., residential address, social security number) unless a party alleges in an affidavit or a pleading under oath that the health, safety, or liberty of a party or child would be jeopardized by disclosure of such information. In that event, the information must be sealed. In some states a tribunal may have authority to make a nondisclosure finding.

If a jurisdiction has reason to believe that information should not be released because of safety concerns, it should ensure that there is a nondisclosure finding or an allegation in an affidavit or the pleading that disclosure of identifying information would result in a risk of harm, as provided under section 312 of UIFSA. In addition to identifying information included on this form, it may be appropriate to submit certain financial information under seal.

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).

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.

Section 1. 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

  

  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 “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 and responding tribunal have assigned to the case.

  
  
  

• Responding tribunal number, if known

Under “IV-D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified 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 which the initiating tribunal or agency has assigned to the case. 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 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 which the initiating tribunal or agency has assigned to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services.

Section 2. Parent/Caretaker Information:

Identify each parent as an obligee or obligor as appropriate. UIFSA defines obligor to include a person alleged to be a parent. Provide the following information in the appropriate boxes:

• Full legal name (last, middle, first, suffix)

• Social Security Number

• Home address (street, city, state, zip code) – include all parts of the address (e.g., apartment number)

Complete the caretaker information only if the child(ren)’s caretaker is someone other than the child(ren)’s parent.

• Full legal name (last, middle, first, suffix)

• Social Security Number

• Home address (street, city, state, zip code) – include all parts of the address (e.g., apartment number)

Section 3. Child(ren) Information:

Identify all of the children for whom support is owed or being sought. For each child, enter:

• Full legal name (last, middle, first, suffix)

• Home address (street, city, state, zip) – include all parts of the address (e.g., apartment number)

• The month and year the child began residing in this state

• Social Security Number

• Date of birth

• Gender

Check “Additional Child(ren) Information Attached” if additional space is needed or if support is owed or sought for more than three children.

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) Publication140-2 (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.

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Personal Information Form for UIFSA § 311 OMB 0970 – 0085 Expiration Date: XX/XX/XXXX Page 1 of 2