Alaska > Statewide > Child Support Services Division
Registration Statement 0970-0085 - Alaska
| Registration Statement Form. This is a Alaska form and can be used in Child Support Services Division Statewide . |
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STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION Please Reply To: CSSD, MS 5 th 550 WEST 7 AVE., SUITE 310 ANCHORAGE, AK 99501-6699 RE: Directions for Completion of Registration Statement Case No: Case Name: v. The Non-Custodial Parent has been located outside the State of Alaska. The enclosed Registration Statement form is required by the other state to enforce or modify your child support order. Please use a ballpoint pen to sign the enclosed form(s) before a Notary Public. Please complete the highlighted sections. I will complete the information in the Case Summary area as well as the information for the other party. *Warning: The information you provide might be released by the state where the other party resides. If the health, safety or liberty of you or your child would be put at risk by disclosure of identifying information, complete the enclosed "Affidavit and Request for Nondisclosure of Identifying Information." If you have already completed this form and been granted Non-Disclosure there is no need to complete it again. The Registration Statement(s) must be returned to our office within 30 days or: a) We may close your case; or b) Public Assistance will be notified of your unwillingness to cooperate. *If you have any questions, please call me at (907) 269Sincerely, Child Support Specialist I Interstate Initiation Section Enclosures CSSD 04-1740B (Rev 8/15/11) TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3220 SOUTHEAST: (907) 465-5887 FAIRBANKS: (907) 451-2830 MAT-SU: (907) 357-3550 American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION STATEMENT Responding IV-D Case Identifier Responding Tribunal Number Initiating IV-D Case Identifier Initiating Tribunal Number Action: [ [ ] Register for Enforcement ] Register for Modification I. Case Summary (Background of this Matter: Court / Administrative Actions) Date of Support Order Support Amount/Frequency $ State and County Issuing Order Date of Last Payment Tribunal Case Number Period of Computation thru Date Date Amount of Arrears $ [ ] Tribunal Has Determined This to Be Controlling Order [ ] Only Order II. Mother Information [ ] Obligor [ ] Obligee Full Name Address (Street, City, State, Zip) (first, middle, last) Aliases, Maiden Name Social Security Number: III. Father Information Full Name (first, middle, last) Aliases Social Security Number: IV. Caretaker (If Not a Parent) Full Name (first, middle, last) Aliases Social Security Number: V. Additional Case Information [ ] Nondisclosure Finding Attached This order is registered in the following states: Description and location of any property not exempt from execution: Relationship to Child(ren) Employer (Name, Street, City, State, Zip) [ ] Obligor [ ] Obligee Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip) [ ] Has legal custody/guardianship of child(ren) Address (Street, City, State, Zip) Other: VI. Verification / Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief. Date [ ] Party Seeking Registration [ ] Records Custodian Sworn to and Signed Before Me This Date, County/State Registration Statement Notary Public, Court/Agency Official and Title Commission Expires OMB 0970 0085 Expiration Date: 05/31/2014 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR REGISTRATION STATEMENT PURPOSE OF THE FORM: The Registration Statement is completed by the initiating jurisdiction to request registration of an existing order for enforcement and/or modification. The purpose of the form is to refer specific order information to the responding State. This form can be used in IV-D and non-IV-D interstate cases. It should be included with the other appropriate forms and directed to the responding State's central registry. In non-IV-D cases, contact the responding State central registry to determine appropriate procedures. It is important to remember that a separate Registration Statement is needed for each order that the initiating State is requesting be registered by the responding State. Italicized text that appears within a "box" refers to policy or provides additional information. HEADING/CAPTION: · In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction's IV-D case identifier, and Tribunal number. Under "IV-D case identifier", 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. Under "tribunal number", you may enter the docket number, cause number, or any other appropriate reference number that the responding State may use to identify the case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. · In the appropriate spaces, enter the Initiating jurisdiction's IV-D case identifier, and tribunal number. Under "IV-D case identifier", 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. Under "tribunal number", you may enter the docket number, cause number, or any other appropriate reference number which the initiating tribunal or agency has assigned to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. ACTION: Check the appropriate box indicating whether you are registering this order for enforcement or modification. NOTE that registration for enforcement should be accompanied by Transmittal #1. Registration for modification should be accompanied by Transmittal #1, Uniform Support Petition, and General Testimony. SECTION I, CASE SUMMARY: Provide complete information for all court/administrative actions regarding support for dependents. Use a separate Registration Statement form for each court/administrative order you are requesting be registered. For the listed order, under "Period of Computation", enter the month, day, and year for both the beginning of the current support obligation
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