Form 1 Agreement to Receive Electronic Lien/Levy Notices

OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

Department of Health and Human Services
Administration for Children and Families
Office of Child Support Enforcement

Agreement to Receive Electronic Lien/Levy Notices
(FAST Levy Financial Institution Profile Form)
By completing the information in the Federally Assisted State Transmitted (FAST) Levy Financial Institution (FI) Profile
Form, the FI agrees to the following conditions:
Electronically receive lien/levy notices issued by a state, tribe, or territory, hereafter referred to as “state.”
Not impersonate any individual, entity, or association, use false headers, or otherwise conceal or submit
misleading information about its identity while receiving electronic lien/levy notices.
Supply true, accurate, current, and complete information about the entity identified on this form.
Receive, handle, and process lien/levy notices electronically transmitted to it in the same way as if received
via regular mail. Any electronic lien/levy notices it receives shall represent records generated during the
ordinary course of business. The electronic lien/levy notice it receives shall be admissible as evidence in the
same way as paper documents. The FI will process the FAST Levy file “as is,” and is not responsible for any
request sent in error or with incorrect data.
Report issues with edit check failures or bugs on the FAST Levy files to the federal Office of Child Support
Enforcement (OCSE) at FASTLevy@acf.hhs.gov.
If the FI is unable to accept electronic FAST Levy requests due to a catastrophic event, it will notify OCSE as
soon as possible. The FI shall let OCSE know when it is able to accept and process electronic lien/levy
notices again. The FI will not be liable for its inability to accept electronic FAST Levy requests due to such an
event.
Send written notice to OCSE at least 60 days in advance of its intent to no longer accept electronic lien/levy
notices.
Not process FAST Levy files on weekends or federally recognized holidays.
The financial institution shall have appropriate procedures in place to promptly report confirmed or suspected
information security or privacy incidents, including, but not limited to, unauthorized use or disclos ure of
Personally Identifiable Information (PII) involving confidential child support information submitted through
OCSE to your organization. As soon as reasonably practicable after discovery, but in no case later than one
hour after discovery of the incident, the financial institution shall report confirmed or suspected incidents to
OCSE as specified in this paragraph. The requirement for the financial institution to report confirmed or
suspected incidents involving PII to OCSE is based on federal guidance/requirements from the Office of
Management and Budget (OMB), Health and Human Services (HHS), the Federal Information Systems Security
Modernization (FISMA) Act of 2014, and the United States Computer Emergency Readiness Team (US -CERT).
Incidents must be reported via email to OCSE using the security mailbox address:
ocsesecurity@acf.hhs.gov

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OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

OCSE agrees to the followin g conditions:
E-mail an acknowledgement to the FI at the address on this form within 24 hours of receiving the electronic
FAST Levy response.
Report issues encountered with file transmissions to the FI at the phone number or e-mail address on this
form.
Report issues with edit check failures or bugs on FAST Levy files to the e-mail address on this form. Key FI
personnel should have access to this mailbox so they can respond to OCSE.
Notify the FI as soon as possible that a state will send paper requests in the event of a catastrophic event, via
e-mail to the address on this form.
Notify the state when the FI is unable to receive FAST Levy requests, and when the FI is able to receive
requests again.

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OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

Instructions
When completing the profile form, fields followed by an asterisk are required. If data is entered incorrectly , a pop-up box may be displayed that includes
instructions about how to enter the data. Please follow the instructions and do not ignore the pop-up box.

General Information
Enter general information about the organization and participation in FAST Levy.
Start Date:

*

(Click o n th e fie ld an d an arro w appe ars to th e righ t o f th e fie ld. Use th e arro w to sh o w a cale n dar. Se le ct a date
fro m th e cale n dar. Wh e n e n te rin g a date in ste ad o f u sin g th e cale n dar, u se th e fo rmat: MM/DD/YYYY.
If th e actu al date is u n kn o wn , e n te r a pro je cte d date .)

FEIN: *

(Prima ry Fe de ral Emplo ye r Ide n tifica tio n Nu mbe r - e n te r as 9 n u mbe rs with o u t a dash afte r th e se co n d n u mbe r th is FEIN is th e FEIN u se d o n th e batch fo r th e file s be in g tran sfe rre d.)

Organization Type: *
(Se le ct if yo u are a fin an cial in stitu tio n o r a tran smitte r.)

Organization Name: *

Organization Short Name:

(Su pply an abbre via tio n o r acro n ym
fo r th e o rgan izatio n su ch as DFAS o r KBR.)

Address Information
Enter required address information.
Address Line 1: *

Address Line 2:

Address Line 3:

City: *

Zip Code:

State: *

Zip Code Extension

*
-

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(Enter 5 numbers for the zip code and an optional 4 number zip
code extension.)

OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

Contact Information
Enter business and technical support contact information. Enter information for the primary and alternate, if applicable,
business contact or technical contact.

Business Contact Information
Enter business contact information.
Contact Name: *

Contact Phone Number: *
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact Fax: *
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact E-mail: *
(En te r as: n ame @so me wh e re .co m)

Click if you want e-mail notifications sent to this e-mail address

Technical Support Contact Information
Enter technical support contact information.
Contact Name: *

Contact Phone Number: *
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact Fax:
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact E-mail: *
(En te r as: n ame @so me wh e re .co m)

Click if you want e-mail notifications sent to this e-mail address

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OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

Alternate Contact Information
Enter additional business or technical contact information. None of the fields are required.

Alternate Business Contact Information
Enter business contact information.
Contact Name:

Contact Phone Number:
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact Fax:
(En te r n u me ric digits o n ly, in clu din g are a co de . fo r e xample , e n te r 1231231111.)

Contact E-mail:
(En te r as: n ame @so me wh e re .co m)

Click if you want e-mail notifications sent to this e-mail address

Alternate Technical Support Contact Information
Enter technical support contact information.
Contact Name:

Contact Phone Number:
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact Fax:
(En te r n u me ric digits o n ly, in clu din g are a co de . Fo r e xample , e n te r 1231231111.)

Contact E-mail:
(En te r as: n ame @so me wh e re .co m)

Click if you want e-mail notifications sent to this e-mail address

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OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

File Information
All files transferred using the FAST Levy batch application must be in text format. Files can be named using the standard
FAST Levy file naming convention or the organization's file naming convention.
Defaults have been chosen based on the selections being made by the majority of the organizations.
Verify the defaults to make sure that the wrong selection is not made for your organization.

General File Information
Enter information related to the file exchange.
E-mail Notification:

Never

Click Always if yo u wan t to re ce ive e -mails fo r n o tifica tio n o f file s re ce ive d,
ackn o wle dgme n t o f file s se n t, an d e rro rs.
Click When Errors if yo u o n ly wan t to re ce ive e -mails wh e n th e re are e rro rs.

Connection Information
Select how you would like to set up your secure connection.
You will be using the FIDM connection that is currently in place for your financial institution.
You want our network team to contact you about setting up a secure connection.

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OMB Control No: 0970-0370
Expiration Date: xx/xx/xxxx

File Process Information
Complete the file information in the file name convention box, including the file name convention to be used.
A. First use the checkboxes in the second column (Standard/Organization Supplied File Name Convention) to select
whether you want to use your file name convention or use the standard file name convention determined by the OCSE
batch application.
B. If you are using your file name convention, you must supply the file name convention in the third column (File Name
Convention). For example, for the file containing withhold requests (Incoming State Files), you might enter: xxx.mybiz.
requests.tx t. This would be the name of the file that you expect to receive that contains your withhold requests. If you are
using the file name conventions from the FAST Levy batch application an example file name is shown. Refer to the FAST Levy
software interface specification for more details about file name conventions and formats.
File Name Convention:
File Type
Lien/Levy Files *

Standard/Organization Supplied
File Name Convention
OCSE Standard

File Name
Convention
(Example: F999.FSTLVYO.FPLS.RYYMMDD )

Organization Supplied
Response Files *

OCSE Standard

(Example: F999.FSTLVYCO.FPLS.RYYMMDD)

Organization Supplied
Response Error Files *

OCSE Standard

(Example: F999.FSTLVYIO.FPLS.R YYMMDD )

Organization Supplied

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this voluntary
information collection is for OCSE to implement the FAST Levy process and capture preferences for financial
institutions. Public reporting estimated burden for this collection of information is 0.08 hours per respondent,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. As provided by 42 U.S.C. § 653(m)(2), any confidential information collected for this
program is accessed only by authorized users. A federal agency may not conduct or sponsor an information collection
without a valid OMB Control Number. No individual or entity is required to respond to, nor s hall an individual or entity
be subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act of 1995, without a current valid OMB Control Number. If you have any comments on this
collection of information, please contact OCSEFedSystems@acf.hhs.gov.

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