Form 1 Annual Certification Letter

Federal Collections & Enforcement Annual Certification Letter OMB Control No. 0970-0161

Expiration Date: xx/xx/xxxx

Annual Certification Letter

Use State Letterhead

Date:

Office of Child Support Enforcement

Department of Health and Human Services

Federal Collections and Enforcement

Mary E. Switzer Building

330 C Street, SW, 5th Floor

Washington, DC 20201

From: __________________, ______________________, ____________________

State IV-D Director Title Jurisdiction

Subject: Request for Collection of Delinquent Child and/or Spousal Support, Denial of Passport Application, Multistate Financial Institution Data and Insurance Matches, using the Federal Collections and Enforcement Process

I certify that every request for offset collection meets the following requirements:

1. (A) For Federal Tax Refund Offset assistance cases, the amount of the delinquency under a court or administrative order for support is not less than $150 and has been assigned to the State.

(B) For Federal Tax Refund Offset non-assistance cases, the amount of the delinquency under a court or administrative order for support is not less than $500 and the State is enforcing the order under section 454(4)(A)(ii) of the Social Security Act (the Act).

(C) For Administrative Offset cases, the amount of the delinquency under a court or administrative order for support is not less than $25 and there has been an assignment of the support rights to the State or the State is enforcing the order under section 454(4)(A)(ii) of the Act.

2. This agency has verified the accuracy of the arrears, has a copy of the order and any modifications, has a copy of the payment record or an affidavit signed by the custodial party attesting to the amount of support owed and has, in non-assistance cases, the custodial party’s current, or last known, address.

3. The Pre-Offset Notice that we will issue to the noncustodial parent meets the requirements set forth in the regulations, or the address information provided for the noncustodial parent was verified for the notice that OCSE will issue.

I certify that every request for passport denial meets the following requirements:

1. The amount of support owed by the individual exceeds $2,500.

2. This agency has verified the accuracy of the arrears, has a copy of the order and any modifications, and has a copy of the payment record or an affidavit signed by the custodial party attesting to the amount of support owed.

3. The Pre-Offset Notice that we will issue to the noncustodial parent meets the requirements set forth in section 454(31) of the Act, or the address information provided for the noncustodial parent was verified for the notice that OCSE will issue.

I certify that every request for multistate financial institution data match and/or insurance match is delinquent.

I certify that appropriate administrative, technical and physical safeguards are in place to insure the security and confidentiality of records and to protect against any anticipated threats or hazards to their security or integrity, which could result in substantial harm, embarrassment, inconvenience or unfairness to any individual on whom information is maintained.

________________________________________________________________________

Information for OCSE Pre-Offset Notice:

We request that OCSE mail Pre-Offset Notices to noncustodial parents. ____Yes ____No

If yes, which address type should be used on your State’s OCSE-issued Pre-Offset Notice?

____ Use State IV-D Return Address/State IV-D Contact Address

____ Use Local Return Address/Local Contact Address

____ Use State IV-D Return Address/Local Contact Address

____ Use Local Return Address/State IV-D Contact Address

State IV-D Address:

All States must provide a State IV-D address and contact information. The State IV-D address below may be used in the OCSE-issued Pre-Offset Notice and/or the Bureau of the Fiscal Service Offset Notice.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Telephone: (______) _______ - ___________________________

Telephone 2 (Optional): (______) _______ - _________________

How long does your State want OCSE to hold new cases from the Pre-Offset Notice date before forwarding to the Bureau of the Fiscal Service for offset certification?

___ 30 days

___ 45 days

___ 60 days

___ 90 days

Signature of IV-D Director or Designee _______________________________

Agency Contact __________________________________________________

Agency Contact's Phone Number ____________________________________

Agency Contact’s E-mail Address ___________________________________

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this statutorily required (42 U.S.C. 652(b); 42 U.S.C. 664; 26 U.S.C. 6402(c); 31 CFR 285.3; 45 CFR 302.60; 45 CFR 303.72; 31 U.S.C. 3701 et seq.; 31 U.S.C. 3716(h); 31 CFR 285.1; 42 U.S.C. 652(k); 42 U.S.C. 654(31); 22 CFR 51.60; 42 U.S.C. 654(31); 42 U.S.C. 664; 31 CFR 285.1; and 31 CFR 285.3) information collection is to collect past due child support. Public reporting estimated burden for this collection of information is 0.4 hours per respondent, including the time for reviewing instructions, gathering, and maintaining the data needed, and reviewing the collection of information. As provided by the 5 U.S.C. §§552a(b) and (e), any confidential information collected for this program is protected secured, and 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 shall 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