1 Administrative Subpoena Form

OMB# 0970 – 0152

Expiration Date: xx/xx/2027

ADMINISTRATIVE SUBPOENA

The information on this form may be disclosed 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.

To: (Name and Address)

File Stamp

Regarding: Legal Name (first, middle, last, suffix )

Alias Name(s)

Date of Birth

Social Security Number

From: (Agency, Address, telephone, e-mail address, fax number)

Section I. Case Identifier:

1.

IV-D Case Number:

Docket Number:

2.

IV-D Case Number:

Docket Number:

3.

IV-D Case Number:

Docket Number:

Section II. Subpoena:

Under the Social Security Act section 466(c)(1)(B) and similar statutes in this and all other states, you are required to provide

financial or other information needed to establish, modify, or enforce a child support order.

Provide the following information or documents by ______________:

(date)

Barcode:

The Paperwork Reduction Act of 1995 (Pub. L. 104-13): STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide uniformity and standardization in the transmission of interstate administrative subpoenas. Public reporting burden for this collection of information is estimated to average .50 hours per form, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required for interstate cases (section 454(9)(E) of the Social Security Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0152 and the expiration date is xx/xx/2027. If you have any comments on this collection of information, please contact OCSS by email at OCSS.DPT@acf.hhs.gov.

ADMINISTRATIVE SUBPOENA, PAGE 2
Section III. Declaration/Notarization:
This section is to be completed by ___________ . The information or documents may be sent by mail, fax, or any other means
agreeable to the requesting agency, including electronic means. Your response to this subpoena must be dated, signed by you or
your designee, and be either [ ] notarized or [ ] witnessed. (You may use the space below the declaration statement to complete
notarization or witness information if required in your state.) Please return a copy of this page with your documentation.
I [ ] declare, [ ] certify, [ ] verify, or [ ] state under penalty of perjury that the foregoing is true and correct.
Executed on ______________.
	(date)
Section IV. Contact Information:
As an authorized agent of a state or county agency responsible for implementing the child support services program set forth in
Title IV, Part D, of the Social Security Act (section 451, et seq.), I have legal authority to issue this subpoena to have
effect in any state. For additional information regarding this subpoena, including how to challenge it, please contact the issuing
agency and reference the IV-D case number.

Date

Authorized Agent Signature

Authorized Agent Printed Name

E-mail

Direct Telephone Number

Fax

Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws

of your state.

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 Services. 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 THE ADMINISTRATIVE SUBPOENA

PURPOSE OF THE FORM:

Purpose of this form: The Administrative Subpoena is the federal form that the state IV-D programs, pursuant to section 454(9)(E) of the Social Security Act, are required to use in interstate cases. A state may elect to use this form in intrastate cases. This form is to be administratively issued by the IV-D program to subpoena financial or other information needed to establish, modify, or enforce a child support order.

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

HEADING/CAPTION:

• The initiating jurisdiction determines the heading.

• In the “To” field place the name and address of the individual or entity on whom you are serving the subpoena. (For example - financial institutions or employer.)

• In the “Regarding” field provide the name, alias name(s), date of birth, and SSN (if available) of the individual you are requesting information about.

Frequently, this will be the noncustodial parent. If you are issuing an administrative subpoena to obtain bulk records for data matching purposes, you may use the “Regarding” field as a subject line.

• In the “From” field place the Child Support Services Agency name, address, telephone number, e-mail address, and fax number.

Section I. Case Identifier:

• In the space following “IV-D Case Number” enter the number/identifier identical to the one submitted on the Federal Case Registry, which is a left-justified, 15-character, alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase.

• In the space following “Docket Case Number” you may enter the court’s docket number, cause number, or any other appropriate reference number that is assigned to the case, which is a left-justified, 15-character, alphanumeric field, allowing all characters except asterisk and backslash, and with all characters in uppercase.

If you are issuing an administrative subpoena to obtain bulk records for data matching purposes, this field is optional.

Section II. Subpoena:

• In the “date” field provide the date that the requested documents are to be provided to you.

• In the space provided, clearly, completely, and specifically describe all records or documents that you are requesting in the subpoena. If you are issuing an administrative subpoena to obtain bulk records for data matching purposes, you may issue one form accompanied by a list of the individuals whose information you are requesting.

Barcode:

• If available, entities using imaging technology can use this area for adding a barcode to the document.

Section III. Declaration/Notarization:

• This section is completed by the entity named under “To” in the header. This is the entity who will be responding to the subpoena.

  

  The sender should enter the name of the entity they are sending the form to where it states:

  “This section is to be completed by ___________ .”

• Depending on their state law, the responding person will check either the “Notarized” box if required OR the “Witnessed” box.

The person responding to the subpoena must indicate in the statement that under penalty of perjury the foregoing is true, and check either “declare”, “certify”, “verify”, or “state”. Include the date the statement was executed on the “date” field.

• The person responding to this subpoena must notarize this declaration if required by their state law. The space below the declaration statement may be used to include notary information.

• If witnessed, the space below the declaration statement may be used.

• The person responding to this subpoena will copy this page and return it with requested documentation.

Section IV. Contact information:

The person issuing the subpoena signs in the “Authorized Agent Signature” field.

• Complete the signature and information for the authorized agent issuing this subpoena, including the date the subpoena is signed; the authorized agent signature and printed name; and the authorized person’s e-mail (if available), direct telephone number, and fax number.

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 Services. 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).

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