Form 1 Child Support Agency Confidential Information

CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM
FOR IV-D AGENCY USE ONLY – DO NOT FILE WITH A TRIBUNAL OR PROVIDE TO THE OTHER PARTY
The information on the form may be disclosed only as authorized by law.
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 I. 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 II. Parent/Caretaker Information:
Parent [ ] Obligee or [ ] Obligor			Parent [ ] Obligee or [ ] Obligor
Legal name (first, middle, last, suffix):			Legal name (first, middle, last, suffix):
Relationship to child(ren):			Relationship to child(ren):
Gender: [ ] Male [ ] Female [ ] Other			Gender: [ ] Male [ ] Female [ ] Other
Date of birth:	Place of birth: (city, county, state)		Date of birth:			Place of birth: (city, county, state)
SSN:		Home telephone:	SSN:		Home telephone:
Cell telephone:		Work telephone:	Cell telephone:		Work telephone:
Alias (e.g., maiden name, nickname):			Alias (e.g., maiden name, nickname):
Home address (street, city, state, zip code): Date address confirmed: ___________________			Home address (street, city, state, zip code): Date address confirmed: ___________________
Mailing address (street, PO Box, city, state, zip code): Date address confirmed: ___________________			Mailing address (street, PO Box, city, state, zip code): Date address confirmed: ___________________
E-mail:			E-mail:
Employer name: Date employer confirmed: __________________			Employer name: Date employer confirmed: __________________
Employer address (street, city, state, zip code):			Employer address (street, city, state, zip code):
Employer FEIN:			Employer FEIN:
Incarcerated? [ ]Yes [ ] No (If yes, Inmate #: ________________________________________ and facility name:_______________________________________)			Incarcerated? [ ]Yes [ ] No (If yes, Inmate #: _________________________________________ and facility name: ________________________________________)
CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM, PAGE 2
Caretaker - Obligee (When obligee is not the child(ren)’s parent)
Legal name (first, middle, last, suffix):
Relationship to child(ren):
Gender: [ ] Male [ ] Female [ ] Other
Date of birth:
SSN:				Home telephone:
Cell telephone:				Work telephone:
Home address (street, city, state, zip code): Date address confirmed: ___________________
Mailing address (street, PO Box, city, state, zip code): Date address confirmed: _____________________
E-mail:
Section III. Child(ren) Information:
Child #1 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):
SSN:			Date of birth:
Place of birth (city, county, state):			Gender: [ ] Male [ ] Female
Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: _________________________)
If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ___________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.

CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM, PAGE 3
Section III. Child(ren) Information (Continued):
Child #2 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):
SSN:	Date of birth:
Place of birth (city, county, state):	Gender: [ ] Male [ ] Female
Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: _________________________)
If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ____________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.
Child #3 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):
SSN:	Date of birth:
Place of birth (city, county, state):	Gender: [ ] Male [ ] Female
Nonmarital birth: [ ] Yes [ ] No (If no, date of marriage: _________________________)
If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ____________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.

[ ] 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 e-mails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

INSTRUCTIONS FOR CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM

PURPOSE OF THE FORM:

This form is for Child Support (IV-D) Agency use only and is not to be filed with a tribunal or provided to the other party. The Child Support Agency Confidential Information Form is intended to safeguard the privacy of individuals by providing a means to record their personally identifiable information on a separate document that is not served on the parties or filed with a tribunal. The information contained in the form is governed by federal and state safeguarding and privacy requirements. This form must always be included with a Child Support Enforcement Transmittal #1 request to open a IV-D intergovernmental case and a Child Support Agency Request for Change of Support Payment Location Pursuant to UIFSA § 319. The Child Support Agency Confidential Information Form is needed for most actions being requested on the Child Support Enforcement Transmittal #2 and the Child Support Enforcement Transmittal #3, since most of the identifying information has been removed from those forms. It should be included with the Child Support Enforcement Transmittal #3 if the IV-D case identifier or tribunal number in the assisting state is unknown.

The information on this form may be disclosed only as authorized by law.

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).

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 I. 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

• Responding tribunal number, 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 tribunals have assigned to the case.

Section II. Parent/Caretaker Information:

Identify each parent as the obligee or obligor, as appropriate. UIFSA defines obligor to include a person alleged to be a parent. For each parent, enter:

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

• Relationship to the child(ren)

• Gender*

• Date of birth

• Place of birth (city, county, state or the foreign country of birth)

• Social Security Number

• Home telephone number

• Cell telephone number

• Work telephone number

• Any known alias (e.g., maiden name, nickname) - an alias may include a person’s former married name.

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

• Date home address was confirmed

• Mailing address (street, PO Box, city, state, zip code) - include all parts of the address (e.g., apartment number)

• Date mailing address was confirmed

• E-mail address that parent prefers for communication

• Employer’s name

• Date employer was confirmed

• Employer’s address (street, city, state, zip code) - include all parts of the address (e.g., suite number)

• Employer Federal Employer Identification Number (FEIN)

• Whether person is Incarcerated:

• If “No,” continue completion of the form.

• If “Yes,” enter the Inmate number, if known, and facility name, if known

Complete the caretaker-obligee information only if the child(ren)’s caretaker is someone other than the child(ren)’s parent. Enter the following information about the caretaker-obligee:

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

• Relationship to the child(ren)

• Gender*

• Date of birth

• Social Security Number

• Home telephone number

• Cell telephone number

• Work telephone number

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

• Date home address was confirmed

• Mailing address (street, PO Box, city, state, zip code) - include all parts of the address (e.g., apartment number)

• Date mailing address was confirmed

• E-mail address that caretaker-obligee prefers for communication

* Gender is defined as "male," "female," or "other". Select "other" if the person does not identify as "male" or "female." 

Section III. Child(ren) Information:

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

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

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

• Social Security Number

• Date of birth

• Place of birth (city, county, state or the foreign country of birth)

• Gender

• Whether this was a nonmarital birth (parents were not married when child was born, also referred to as “born out of wedlock” or BOW)

• If “No”, enter the date of the marriage.

• If “Yes”, this is a nonmarital birth, complete the information below.

• Check "Parentage established" if parentage has already been established (the legal parent-child relationship between a child and unmarried parents has been determined). Check the appropriate box to indicate whether the parentage establishment was a paternity determination of fatherhood. “Paternity” is defined as the legal establishment of fatherhood for a child, either by court determination, administrative process, or voluntary acknowledgment.

• Enter the date parentage was established and the state in which parentage was established.

• Identify how parentage was established - by order of a tribunal, by acknowledgment of parentage, by adoption, or by other legal process under state law.  If “Other,” describe how the parent-child relationship was established.

• Check “Parentage not established” if parentage has not been established.

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

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) Publication 140-2 (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.

Child Support Agency Confidential Information Form OMB 0970 – 0085 Expiration Date: XX/XX/XXXX Page 1 of 3