"Child Support Agency Request for Change of Support Payment Location Pursuant to Uifsa 319"

Child Support Agency Request for Change of Support Payment Location Pursuant to Uifsa 319 is a 8-page legal document that was released by the U.S. Department of Health and Human Services - Administration for Children & Families and used nation-wide.

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CHILD SUPPORT AGENCY REQUEST FOR CHANGE OF SUPPORT
PAYMENT LOCATION PURSUANT TO UIFSA § 319
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.
Child Support Agency Confidential Information Form must be attached.
File Stamp
To:
(Agency Name and Address)
Order-Issuing Locator Code: _____________ State ______________
Order-Issuing Case Identifier: __________________________________
Order-Issuing Tribunal Number: __________________________________
From:
(Agency Name and Address)
Requesting Locator Code:
State
________________
_________________
Requesting IV-D Case Identifier: __________________________________
Send Payments To:
(If different from above)
Payment Locator Code: _____________ State ______________
Remittance Identifier: __________________________________
NOTE:
Nondisclosure Finding/Affidavit attached
[ ]
[ ] This form sent through EDE
The following facts exist to permit this request under UIFSA § 319(b):
The obligee receives IV-D services from the requesting agency;
A tribunal in the requested state issued the support order; and
Neither the obligor, the individual obligee, nor the child(ren) reside in the order-issuing state.
Section I. Action:
The requesting agency requests the support enforcement agency or tribunal in the order-issuing state to:
direct that the support payment be made to the requesting agency’s state disbursement unit,
issue and send to the obligor’s employer a conforming income withholding order or an administrative notice of change of
payee, reflecting the redirected payments, and
forward to the requesting agency a copy of the tribunal order or administrative notice redirecting support payments, and the
conforming income withholding order or administrative notice of change of payee.
[ ] The requesting agency also requests a certified arrears calculation (if available) or a payment record as of the date of the
redirection order or administrative notice.
Section II. Case Summary:
Date of Support Order
State and County Issuing Order
Tribunal Number
Support Amount/Frequency
[ ] A copy of the issuing tribunal’s support order is attached.
Section III. Obligee Information:
[ ] Parent [ ] Caretaker
Legal name
(first, middle, last, suffix):
__________________________________________________________________________________________________
If caretaker: Relationship to child(ren): __________________________________ [ ] Has legal custody/guardianship of child(ren)
Child Support Agency Request for Change of Support
OMB 0970 – 0085
Expiration Date: 12/31/2022
Page 1 of 2
Payment Location Pursuant to UIFSA § 319
CHILD SUPPORT AGENCY REQUEST FOR CHANGE OF SUPPORT
PAYMENT LOCATION PURSUANT TO UIFSA § 319
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.
Child Support Agency Confidential Information Form must be attached.
File Stamp
To:
(Agency Name and Address)
Order-Issuing Locator Code: _____________ State ______________
Order-Issuing Case Identifier: __________________________________
Order-Issuing Tribunal Number: __________________________________
From:
(Agency Name and Address)
Requesting Locator Code:
State
________________
_________________
Requesting IV-D Case Identifier: __________________________________
Send Payments To:
(If different from above)
Payment Locator Code: _____________ State ______________
Remittance Identifier: __________________________________
NOTE:
Nondisclosure Finding/Affidavit attached
[ ]
[ ] This form sent through EDE
The following facts exist to permit this request under UIFSA § 319(b):
The obligee receives IV-D services from the requesting agency;
A tribunal in the requested state issued the support order; and
Neither the obligor, the individual obligee, nor the child(ren) reside in the order-issuing state.
Section I. Action:
The requesting agency requests the support enforcement agency or tribunal in the order-issuing state to:
direct that the support payment be made to the requesting agency’s state disbursement unit,
issue and send to the obligor’s employer a conforming income withholding order or an administrative notice of change of
payee, reflecting the redirected payments, and
forward to the requesting agency a copy of the tribunal order or administrative notice redirecting support payments, and the
conforming income withholding order or administrative notice of change of payee.
[ ] The requesting agency also requests a certified arrears calculation (if available) or a payment record as of the date of the
redirection order or administrative notice.
Section II. Case Summary:
Date of Support Order
State and County Issuing Order
Tribunal Number
Support Amount/Frequency
[ ] A copy of the issuing tribunal’s support order is attached.
Section III. Obligee Information:
[ ] Parent [ ] Caretaker
Legal name
(first, middle, last, suffix):
__________________________________________________________________________________________________
If caretaker: Relationship to child(ren): __________________________________ [ ] Has legal custody/guardianship of child(ren)
Child Support Agency Request for Change of Support
OMB 0970 – 0085
Expiration Date: 12/31/2022
Page 1 of 2
Payment Location Pursuant to UIFSA § 319
CHILD SUPPORT AGENCY REQUEST FOR CHANGE OF SUPPORT PAYMENT LOCATION
PURSUANT TO UIFSA § 319, PAGE 2
Section IV. Obligor Information:
Legal name
(first, middle, last, suffix)
: ________________________________________________________________________________________________
Section V. Dependent Child(ren) Information:
Legal name(s)
(first, middle, last, suffix):
Section VI. Other Pertinent Information
:
[ ] Additional case information attached
Section VII. Contact Information:
Date
Contact person (first, middle, last, suffix)
Direct telephone number and extension
Fax:
(
)
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 Agency Request for Change of Support Payment Location Pursuant to UIFSA § 319
Page 2 of 2
RESPONSE TO THE CHILD SUPPORT AGENCY REQUEST FOR CHANGE
§
OF SUPPORT PAYMENT LOCATION PURSUANT TO UIFSA
319
If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution,
File Stamp
or copying of this form or its contents is strictly prohibited.
To:
(Agency Name and Address)
Order-Issuing Locator Code:
State
Order-Issuing Case Identifier:
Order-Issuing Tribunal Number:
From:
Agency Name and Address)
(
Requesting Locator Code:
State
Requesting IV-D Case Identifier:
NOTE:
Nondisclosure Finding/Affidavit attached
[ ]
[ ] This form sent through EDE
The following facts exist to permit this request under UIFSA § 319(b):
The obligee receives IV-D services from the requesting agency;
A tribunal in the requested state issued the support order; and
Neither the obligor, the individual obligee, nor the child(ren) reside in the order-issuing state.
Section I. Response:
The state IV-D agency in the order-issuing state:
1.
[ ] Provides a copy of the tribunal order or administrative notice changing the payment location of the support order to the
requesting agency’s state disbursement unit.
2.
[ ] Provides a copy of the conforming income withholding order or administrative notice reflecting the redirected payments:
[ ] Attached income withholding order or administrative notice was sent to the following known employer:
________________________________________________________________________________
[ ] Employer is unknown.
3.
[ ] Provides a certified arrears calculation
or payment record as of the date of the redirection order or notice.
(if available)
4.
[ ] The limited grounds for UIFSA § 319(b) are not met.
(See information provided in section II.)
5.
[ ] Other
(Explain in section II.)
[ ] Additional case information attached
Section II. Other Pertinent Information:
Section III. Contact Information:
Direct telephone number and extension
Date
Contact person
(first, middle, last, suffix)
E-mail: __________________________________________________________
Fax:
(
)
_____
Response to the Child Support Agency Request for Change
OMB 0970 – 0085
Expiration Date: XX/XX/XXXX
Page 1 of 2
of Support Payment Location Pursuant to UIFSA § 319
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).
Response to the Child Support Agency Request for Change
Page 2 of 2
Payment Location Pursuant to UIFSA Section 319(b)
INSTRUCTIONS FOR THE CHILD SUPPORT AGENCY REQUEST FOR CHANGE OF SUPPORT PAYMENT
§
LOCATION PURSUANT TO UIFSA
319 AND RESPONSE
PURPOSE OF THE FORM:
This form may be used by a IV-D agency, which is providing services to an obligee, to make a request to the state that
issued the support order to change the payment location of the order. UIFSA section 319(b) authorizes the request only
under limited circumstances, detailed on the form and in these instructions. This form may also be used by a IV-D agency
responding to a request under section 319(b) of UIFSA.
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.
A CSE Transmittal #1 does not need to be submitted with this form.
The Child Support Agency Confidential Information Form must be attached. For purposes of this action, the order-
issuing state will need the state of residence of the obligor, the obligee, and the child. Employer-related information is
also on the Child Support Agency Confidential Information form.
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.
HEADING/CAPTION:
The requesting state determines and completes the headings for both the Child Support Agency Request for Change
of Support Payment Location Pursuant to UIFSA § 319 form and the Response page.
In the space marked “To:”, list the name and address (street, PO Box, city, state, and zip code) of the agency to which
you are sending the request for change of support payment location pursuant to section 319(b) of UIFSA.
In the appropriate spaces enter the order-issuing state’s case identifier and tribunal number. The case may be IV-D or
non-IV-D in the order-issuing state.
The order-issuing state is the state that issued the order and is responding to a request of the requesting state.
Under “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 issuing tribunal has assigned to the case.
In the space marked “From:”, list your agency’s name and address (street, PO Box, city, state, and zip code).
In the appropriate spaces, enter the requesting state’s locator code, state, and IV-D case identifier.
The requesting state is the state that is requesting assistance from the order-issuing state. 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.
In the space marked “Send Payments To:”, list the name and address (street, PO Box, city, state, and zip code) of
your agency’s state disbursement unit (SDU) if it is not the same information as listed in “To:” above.
In the appropriate spaces, enter the SDU locator code and state where payments should be sent. Provide the
requesting agency’s remittance identifier as needed, to be included on the order-issuing state’s conforming income
withholding order or administrative notice of change of payee.
In the “NOTE:” section, check any of the following that apply:
Nondisclosure Finding/Affidavit attached
- If there is a finding prohibiting disclosure of a party’s or
child(ren)’s address/identifying information or an affidavit alleging that disclosure of such information would result in
risk of harm, check the box for “Nondisclosure Finding/Affidavit attached” and attach a copy of the finding/affidavit in
accordance with section 312 of UIFSA. If there is a finding/affidavit prohibiting disclosure, the information must be
sealed and may not be disclosed to the other party or the public. You may provide the address of the IV-D agency
as a substitute address for the protected party.
Child Support Agency Request for Change of Support Payment Location Pursuant to UIFSA § 319 Instructions
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