Child Support Enforcement Transmittal 1 Intial Request {UIFSA-1}

IV-D Case: [ ] TANF [ ] IV-E Foster Care [ ] Medicaid Only [ ] Former Assistance [ ] Never Assistance CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST The information on this form may be disclosed as authorized by law. File Stamp 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. Child Support Agency Confidential Information Form must be a ttached . Petitioner: Legal Name (first, middle, last, suffix) Tribal Affiliation (if applicable) Respondent: Legal Name (first, middle, last, suffix) Tribal Affiliation (if applicable) Responding Locator Code: State To: (Agency Name and Address) Responding IV-D Case Identifier: Responding Tribunal Number: From: (Agency Name and Address) Initiating Locator Code: State Initiating IV-D Case Identifier: Initiating Tribunal Number: Send Payments To: (If different from above) 003 Payment Locator Code: State NOTE: [ ] Nondisclosure Finding/Affidavit attached [ ] This form sent through EDE [ ] This request or information sent through CSENet Section I . Action: The responding j urisdiction s hould open an intergovernmental case with the initiating jurisdiction and provide all appropriate services , including: (Please return the acknowledgment form . ) 1. [ ] 003 Establish parentage 4. [ ] Take the following action on a support order of another 2. 003 [ ] Establish and enforce order, and forward payment to the jurisdiction and forward payment to the initiating initiating jurisdiction222s SDU for: jurisdiction 222s SDU: A. [ ] Current child support, including medical support A. [ ] Register and e B. [ ]003 Retroactive child support B. [ ] Register, m odify , and enforce C. [ ]003 Medical support only C. [ ] Register , modify , then close the 3. 003 [ ] Take the following action (s) on the responding tribunal 222s intergovernmental IV - D case order and forward payment to the initiating jurisdiction 222s SDU: D . [ ] Register and e nforce arrears only A. [ ] 003Enforce 5 . [ ] Other B. [ ]003 Modify and enforce C. [ ] 003M odify then close the intergovernmental IV - D case D . [ ]003 Enforce arrears only E . [ ] 003 Change pe rson/entity entitled to receive funds and enforce Section II. Case Summary : (Background of this matter: court/administrative actions)002 Date of support o rder State and county, t ribe , or f oreign country issuing o rder Tribunal n umber002 Support a mount/ f requency Date of l ast p ayment Total amount of a rrears Period of c omputation002 $ $ through002 [ ] Current Support [ ] Arrears Only002 Child Support Enforcement Transmittal #1 226 Initial Request OMB 0970 226 0085 Expiration Date: 12/31/2019 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 - INITIAL REQUEST, P AGE 2002 Section II. Case Summary (Continued) : Date of support o rder State and county, t ribe , or foreign country issuing o rder Tribunal n umber Support a mount/ f requency Date of l ast p ayment Total amount of a rrears Period of c omputation $ $ thru [ ] Current Support [ ] Arrears Only [ ] Addi tional orders or information attached. Section III . Obligee Information : [ ] Parent [ ] Caretaker Obligee legal name (first, middle, last, suffix) If caretaker: r elationship to child(ren) [ ] Has legal custody/guardianship of the child(ren) Section IV. Obligor Information : Obligor legal n ame (first, middle, last , suffix ) Section V. Depe ndent Child ( ren ) Information : L egal N ame (first, middle, last , suffix ) VI. Other Pertinent Information : [ ] Continued on attached sheet(s), incorporated by reference. VII. Attachments : (Supporting Documentation) [ ] Child Support Agency Confidential Information Form for IV-D Use Only [ ] Uniform Support Petition [ ] Declaration in Support of Establishing Parentage [ ] General Testimony [ ] Personal Information Form for UIFSA 247 311 [ ] Support order(s) [ ] Letter of Transmittal Requesting Registration [ ] Acknowledgment of parentage [ ] Payment history [ ] Birth certificate/birth record [ ] Arrears balance and/or accrued interest (affidavit of arrears) [ ] Nondisclosure finding/affidavit [ ] Arrears calculation (month by month) [ ] Other attachments VII I . Contact Information: ( ) Date Initiating contact p erson (first, middle, last , suffix ) Direct t elephone n umber and e xtension F ax : ( ) E - mail : 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). Child Support Enforcement Transmittal #1 226 Initial Request Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 INITIAL REQUEST PURPOSE OF THE FORM: The CSE Transmittal #1-Initial Request form is required for initiating an intergovernmental case to any responding state222s central registry. It contains basic case information and space for indicating which services are requested. The form can be used to request a number of different actions, including establishment of parentage and/or a support obligation, modification, and/or enforcement. It does not take the place of, and therefore must be accompanied by, the appropriate standard intergovernmental forms (e.g., Uniform Support Petition, Personal Information Form for UIFSA 247311, General Testimony, Declaration in Support of Establishing Parentage, Letter of Transmittal Requesting Registration) and supporting documentation. Whenever possible, a Transmittal #1 request should be sent electronically using the appropriate CSENet transaction. However, some states also require a paper Transmittal #1. The information on this form may be filed with the tribunal and may be disclosed to the parties in the case, unless accompanied by a nondisclosure finding/affidavit. 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. The Child Support Agency Confidential Information Form must be attached. HEADING/CAPTION: 225 The initiating jurisdiction determines the heading. 225 Identify the petitioner and respondent by full legal name (first, middle, last, suffix) and, if applicable, include the name of the tribe with which the petitioner or respondent is affiliated. 225 Check the appropriate box to identify the type of IV-D case: TANF, IV-E foster care, Medicaid only, former assistance, or never assistance. Once an initial referral in a IV - D case has been made to the responding state222s central registry (using a CSE Transmittal #1), subsequent communication should occur with the agency/court/jurisdiction that is actually working the case (using a CSE Transmittal #2). 225 In the appropriate spaces, enter the responding jurisdiction222s locator code, state, and, if applicable and known, IV-D case identifier and tribunal number. Italicized text that appears within a 223box224 refers to policy or provides additional information. TANF means the obligee222s family is currently receiving IV-A cash payments. A Medicaid only case is a case in which the obligee222s family receives Medicaid but does not receive TANF. A former assistance case might be a case for state arrears only or for a family that previously received TANF, but is not doing so at this time. For a n 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. If this is a tribal IV-D case, note that tribal locator codes uniquely identify tribal cases with 2239224 in the first posi