Form 1 Certification Letter

OMB Control NO: 0970-0183

Expiration Date: X/XX/XXXX

To: Division of Federal Systems, Office of Child Support Enforcement

ATTN: Joan O’Connor

Administration for Children and Families

370 L’Enfant Promenade, SW, 4th Floor

Washington, DC 20447

From: ________________________________________________(State IV-D Director)

________________________________________________(State Organization)

________________________________________________(Address)

________________________________________________

________________________________________________

Re: Annual Certification to Request Information from Forms 1099 on the Wage and
Information Document Master File for Project 1099

I certify that Project 1099 return information received from the Federal Parent Locator Service/Federal Case Registry is needed for the purpose of, and will be used only to the extent necessary for the purpose of establishing paternity or to establish, set the amount of, or modify a child support obligation; and to enforce a child support obligation pursuant to Part D, Title IV of the Social Security Act. None of the information so obtained will be disclosed to third parties or in litigation relating to the establishment or enforcement of child support obligations. The information sought is not reasonably available from any other source.

In order to comply with the safeguarding requirements of the Internal Revenue Code Section 6103 (p) (4), we agree to adhere to the safeguards for protecting Federal tax returns and return information as contained in Department of the Treasury - Internal Revenue Service Publication 1075 (Rev 6/00) “Tax Information Security Guidelines for Federal, State and Local Agencies - Safeguards for Protecting Federal Tax Returns and Return Information.”

_________________ from: to: September 30, 20xx

State Certification Period

______________________________________________________________________

Name, Title, of IV-D Director or Designee

____________________________________________________________________ ____________

Signature Date Signed

______________________________________________________

Name and Telephone Number to Contact Regarding 1099

The Paperwork Reduction Act of 1995

Public reporting burden for this collection of information is estimated to average .48 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.