New York > Statewide > Family Court > Uniform Interstate Family Support Act
Child Support Enforcement Transmittal 1 Intial Request UIFSA-1 - New York
| Child Support Enforcement Transmittal 1 Intial Request Form. This is a New York form and can be used in Uniform Interstate Family Support Act Family Court Statewide . |
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CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST Petitioner Respondent [ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) [ ] Non-IV-D File Stamp To: (Agency Name and Address) Responding FIPS Code ________________ State _________________________ Responding IV-D Case No. _____________________________________________ Responding Docket No. ________________________________________________ From: (Contact Person, Agency, Address, Phone, Fax, Internet) Initiating FIPS Code __________________ State __________________________ Initiating IV-D Case No. ________________________________________________ Initiating Docket No. ___________________________________________________ Send Payments To: (if different from above) Payment FIPS Code ___________________ State _________________________ Bank Account ________________________ Initiating Jurisdiction Routing Code _________________ [ ] URESA [ ] UIFSA State with Continuing Exclusive Jurisdiction (CEJ) _______________________ I. Action. 1. The Responding Jurisdiction Should Provide All Appropriate Services Including: [ ] Establishment of Paternity 2. [ ] Establishment of Order for: A. B. 6. [ ] Registration of Foreign Support Order: [ ] For Enforcement Only C. [ ] For Modification B. [ ] For Modification and Enforcement Requested by: [ ]Obligor [ ]Obligee [ ]State Agency A. (Requires Sworn Statement of Arrears) [ ] Child Support D. [ ] Medical Coverage [ ] Spousal Support E. [ ] Other Costs (Use Sec. VII) C. [ ] Support for a Prior Period 7. [ ] Enforcement of Responding Tribunal Order 4. [ ] Modification of Responding Tribunal Order 5. [ ] Change of Payee/Redirection of Payment 3. Please Return the Acknowledgment Attached (3 of 3) II. Case Summary (Background of this Matter: Court/Administrative Actions) Date of Support Order State & County Issuing Order Tribunal Case No. [ ] Collection of Arrears 8. [ ] Income Withholding 9. [ ] Administrative Review for Federal Tax Offset 10. [ ] Other __________________________________ Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation $ $ __________thru__________ ....................................................................................... [ ] Presumed Controlling Order [ ] Determined Controlling Order Date of Support Order State & County Issuing Order Tribunal Case No. Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation $ $ __________thru__________ ....................................................................................... [ ] Presumed Controlling Order [ ] Determined Controlling Order Date of Support Order State & County Issuing Order Tribunal Case No. Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation $ $ __________thru__________ ....................................................................................... [ ] Presumed Controlling Order [ ] Determined Controlling Order Child Support Enforcement Transmittal #1 - Initial Request OMB No. 0970 - 0085 Page 1 of 3 2001 © American LegalNet, Inc. Dat CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1- INITIAL REQUEST Initiating IV-D Case No. III. Mother Information [ ] Obligor [ ] Obligee Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip) (First, Middle, Last) Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth______________ _______________________ Social Security No._________________________ Date Place IV. Father Information Full Name and Aliases (First, Middle, Last) [ ] Obligor Address [ ] Obligee (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip) Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth______________ _______________________ Social Security No._________________________ Date Place V. Caretaker (If Not a Parent) Full Name and Aliases (First, Middle, Last) Relationship to Child(ren)_________________________________________________ Address (Street, City, State, Zip) Employer/Address (Name, Street, City, State, Zip) Home Phone ( ) [ ] Address Confirmed ___________ [ ] Employer Confirmed ____________ Date Date Work Phone ( ) Date/Place of Birth_____________ ______________________ Sex____ Social Security No._______________________ Date Place M/F VI. Dependent Children Information Full Name (First, Middle, Last) Date of Birth Sex Social Security No. State of Residence for last 6 months VII. Additional Case Information [ ] Nondisclosure Finding Attached VIII. Attachments (Supporting Documentation) [ [ [ [ [ [ ] Arrears Statement/Payment History [ ] Uniform Support Petition (3 Copies) ] General Testimony/Affidavit [ ] Affidavit in Support of Establishing Paternity ] Acknowledgment of Parentage ] Other Documents Relating to Paternity Initiating Contact Person (Print or Type) ] Support Order(s) [ ] Divorce Decree ] Assignment of Rights [ ] Description of Real/Personal Property [ ] Photograph of Respondent [ ] Other Attachments (________)_________________________ Telephone Number & Extension Fax Number _____________________ Date ___________________________________________ (________)_________________________ Child Support Enforcement Transmittal #1 - Initial Request Page 2 of 3 2001 © American LegalNet, Inc. CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST Petitioner Respondent [ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) [ ] Non-IV-D File Stamp To: (Agency Name and Address) Responding FIPS Code ________________ State _________________________ Responding IV-D Case No. _____________________________________________ Responding Docket No. ________________________________________________ From: (Contact Person, Agency, Address, Phone, Fax, Internet) Initiating FIPS Code __________________ State __________________________ Initiating IV-D Case No. ________________________________________________ Initiating Docket No. ___________________________________________________ Send Payments To: (if different from above) Payment FIPS Code ___________________ State _________________________ Bank Account ________________________ Routing Code __________________ Initiating Jurisdiction
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