Child Support Enforcement Transmittal Form – Fill Out and Use This PDF

CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 ­ INITIAL REQUEST Initiating IV­D Case Identifier

III. Mother Information	[ ] Obligor	[ ] Obligee
Full Name (first, middle, last)		Address (Street, City, State, Zip)	Employer/Address (Name, Street, City, State, Zip)

Maiden Name, Alias, Former Married Name, Nickname, etc.

Home Phone (

)

[ ] Address Confirmed

[ ] Employer Confirmed

Work Phone (

)

Date

Date

Date/Place of Birth

Social Security Number

Date

Place

IV. Father Information

[

] Obligor

[ ] Obligee

Full Name (first, middle, last)

Address (Street, City, State, Zip)

Employer/Address (Name, Street, City, State, Zip)

Alias, Nickname

Home Phone (

)

[

] Address Confirmed

[ ] Employer Confirmed

Work Phone (

)

Date

Date

Date/Place of Birth

Social Security Number

Date

Place

V. Caretaker

Relationship to Child(ren)

Full Name (first, middle, last)

[

] Has Legal Custody/Guardianship of Child(ren) (copy of order attached)

Address (Street, City, State, Zip)

Employer/Address (Name, Street, City, State, Zip)

Maiden Name, Alias, Former Married Name, Nickname, etc.

Home Phone (

)

[ ] Address Confirmed

[ ] Employer Confirmed

Work Phone ( )

Date

Date

Date/Place of Birth

Sex

Social Security Number

Date

Place

M/F

VI. Dependent Children Information

Full Legal Name

(first, middle, last)

City, State, Date of Birth

Sex

Social Security Number

State of Residence

for

months

Born Out of Wedlock

[ ] Yes [ ] No

If established, Paternity Establishment Date

VII. Additional Case Information

[ ]

Additional Case Information Attached

[ ] Nondisclosure Finding Attached

VIII.

Attachments

(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

Initiating Contact Person (first, middle, last)

Telephone Number & Extension

FAX:

(

)

E­mail

Child Support Enforcement Transmittal #1 – Initial Request

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INSTRUCTIONS FOR CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 INITIAL REQUEST

PURPOSE OF THE FORM:

The CSE Transmittal #1­Initial Request form is a “cover letter” required to refer IV­D interstate cases to any responding State’s central registry. The form can also be used in non­IV­D cases. It contains basic case information and space for indicating which services are requested. The form can be used to request administrative or legal action, including establishment of paternity and/or support obligation, modification, or enforcement. It does not take the place of, and therefore must be accompanied by, the appropriate standard interstate forms (e.g. Uniform Support Petition, General Testimony, etc.) and supporting documentation. A registration statement is needed for each order that the initiating State is requesting be registered by the responding State. Transmittal #1 may be sent electronically using the appropriate CSENet transaction.

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

HEADING/CAPTION (Pages 1 & 2):

The initiating jurisdiction determines the heading. Note that the heading appears on both page 1 of the Child Support Enforcement Transmittal #1 and on page 3, the Acknowledgment page.

•Identify the petitioner and respondent by name (first, middle, last), Social Security Number, and, if applicable, include the name of the tribe or country in which the petitioner or respondent is associated.

•Check the appropriate space to identify the type of case: TANF; IV­E Foster Care, Medicaid only; former assistance, never assistance, or Non­IV­D.

TANF means the obligee’s family receives IV­A cash payments. A Medicaid only case is a case where the obligee’s family receives Medicaid but does not receive TANF (IV­A cash payments).

•In the space marked “To:”, list the name and address (street, city, State, and zip code) of the court or agency where you are sending the CSE Transmittal #1. NOTE: This information should be entered into the space marked “From:” on page 3.

Once an initial referral in a IV­D case has been made to the responding State’s central registry (using CSE Transmittal #1), subsequent communication can occur with the local agency/court/jurisdiction that is actually working the case (using CSE Transmittal #2).

•In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction’s FIPS code, State, IV­D case identifier, and Tribunal number.

Under “IV­D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left­justified 15­character 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 State may use to identify the case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction.

•In the space marked “From:”, list a contact person, agency name, address (street, city, State, zip code), phone number (including extension), FAX number, and E­Mail address. NOTE: This information should be entered into the space marked “To:” on page 3.

•In the appropriate spaces, enter the Initiating jurisdiction’s FIPS code, State, and IV­D case identifier, and tribunal number.

Under “IV­D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left­justified 15­character 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.

Instructions for Child Support Enforcement Transmittal #1 – Initial Request

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•In the space marked “Send Payments To:” enter the address to which payments should be sent, if the address is different from the agency address provided on the form in the space above.

•In the appropriate spaces, enter the FIPS code and State where payments should be sent.

•If funds can be transmitted electronically via Electronic Funds Transfer (EFT), enter the bank account number under “Bank Account” and the bank routing code under “Routing Code”

SECTION I (page 1), ACTION:

Check the appropriate box(es) to indicate which actions are requested. Multiple actions may be requested, as appropriate.

In IV­D cases, the responding jurisdiction should provide the full range of appropriate services. For example, even if the initiating IV­D agency only checks box 1 “Establishment of Paternity”, the responding jurisdiction should establish paternity, establish a support order, and enforce the support order.

•Check item 1 “Establishment of Paternity” where paternity has not been determined. In a IV­D case, ask another State to establish paternity only if use of long­arm jurisdiction is not available or not appropriate. Be sure to attach an “Affidavit in Support of Establishing Paternity” for each child whose paternity is at issue.

•Check item 2 “Establishment of Order for” to request that an order be established. Indicate the type of order by checking the appropriate box.

•Check item 2A “Current Child Support, including Medical Support” to request the initial establishment of a new child support order.

If an order governing the same obligor, obligee, and child(ren) already exists, you should only request establishment of a new order if: (1) there is more than one existing order, (2) the obligor, obligee, and child have all moved out of the issuing States, and (3) the parties have NOT filed written consent allowing an issuing State to assert jurisdiction

•Check item 2B “Retroactive Child Support” if seeking support for a prior period.

States may establish child support awards covering a prior period, but such awards must be based on guidelines and take into consideration either the current earnings and income at the time the order is set or the obligor’s earnings and income during the prior period. The award of back support is not required under Federal rules, but may be appropriate in accordance with State law. Not all States have authority to establish support orders for prior periods. Medical support must be requested in all IV­D establishment cases.

•Check item 2C “Medical Support Only” in a Medicaid case where a child support order does not exist and is not sought. If seeking to add medical support to an existing child support order, check item 4, “Modification of Responding Tribunal Order.”

•Check item 2D “Spousal Support” to request establishment of a spousal support order. Do not check this item in a IV­D case; establishment of spousal support is not a IV­D function. When requesting establishment of spousal support, contact the support enforcement agency for the appropriate procedure.

•Check item 2E “Costs and Fees” to request an order for costs and fees such as: costs of the delivery of the child, other medical costs not covered by insurance, genetic testing, and attorney’s fees. Describe the costs in section VII “Additional Case Information”.

•Check item 3 “Enforcement of Responding Tribunal Order” to request enforcement of an existing order that was issued by the responding tribunal.

If multiple orders governing the same obligor, obligee, and child(ren) exist, do not ask the responding State to prospectively enforce (or modify) an order unless that order is the “controlling order” that has priority under UIFSA.

UIFSA contains rules for determining which order is recognized when multiple orders exist. Under these rules:

1.The order issued by a tribunal with continuing, exclusive jurisdiction (CEJ) has priority. An issuing tribunal retains CEJ as long as the issuing State remains the residence of the obligor, obligee, or child, or until all parties file written consent with the tribunal allowing another State to assume CEJ.

2.If more than one issuing tribunal would have CEJ, the order issued by the child’s current home State has priority. “Child Home State” is the State where the child has lived for the prior consecutive 6 months before filing the UIFSA action or, if the child is under 6 months of age, since birth.

Instructions for Child Support Enforcement Transmittal #1 – Initial Request

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