Form 3 Annual Certification Letter

Use State Letterhead

Date:

Office of Child Support Enforcement

Department of Health and Human Services

Federal Collections and Enforcement

370 L'Enfant Promenade, S.W.

Washington, D.C. 20447

From: ______________________, ______________________, _______________________

State IV-D Director Title Jurisdiction

Subject: Request for Collection of Delinquent Child and/or Spousal Support, Denial of Passport Application, Multistate Financial Institution Data and Insurance Matches, using the Federal Collections and Enforcement Process

I certify that every request for offset collection meets the following requirements:

1. (A) For Federal Tax Refund Offset assistance cases, the amount of the delinquency under a court or administrative order for child and/or spousal support is not less than $150 and has been assigned to the State.

(B) For Federal Tax Refund Offset non-assistance cases, the amount of the delinquency under a court or administrative order for child support is not less than $500 and the State is enforcing the order under section 454(4)(A)(ii) of the Social Security Act (the Act).

(C) For Administrative Offset cases, the amount of the delinquency under a court or administrative order for support (for a child and the parent with whom the child is living) is not less than $25 and there has been an assignment of the support rights to the State or the State is enforcing the order under section 454(4)(A)(ii) of the Act.

2. This agency has verified the accuracy of the arrears, has a copy of the order and any modifications, has a copy of the payment record or an affidavit signed by the custodial parent attesting to the amount of support owed and has, in non-assistance cases, the custodial parent's current address.

3. The Pre-Offset Notice that we will issue to the obligor meets the requirements set forth in the regulations, or the address information provided for the non-custodial parent was verified for the notice that OCSE will issue.

I certify that every request for passport denial meets the following requirements:

1. The amount of the child support arrearage owed by the individual exceeds $2,500.

2. This agency has verified the accuracy of the arrears, has a copy of the order and any modifications, and has a copy of the payment record or an affidavit signed by the custodial parent attesting to the amount of support owed.

3. The Pre-Offset Notice that we will issue to the obligor meets the requirements set forth in section 454(31) of the Act, or the address information provided for the non-custodial parent was verified for the notice that OCSE will issue.

I certify that every request for multistate financial institution data match and/or insurance match meets the following requirements:

1. There is a delinquent amount of child and/or spousal support owed.

2. The amount of the delinquency is greater than zero.

I certify that appropriate administrative, technical and physical safeguards are in place to insure the security and confidentiality of records and to protect against any anticipated threats or hazards to their security or integrity, which could result in substantial harm, embarrassment, inconvenience or unfairness to any individual on whom information is maintained.

___________________________________________________________________________

Information for Pre-Offset and/or Financial Management Services (FMS) Offset Notice:

We request that OCSE mail Pre-Offset Notices to non-custodial parents. _____Yes _____No

Which address type should be used on your State’s OCSE-issued Pre-Offset Notice and/or Treasury’s FMS Offset Notice?

Choose one of the following for each category:

OCSE-Issued Pre-Offset Notice:

____ Use State IV-D Return Address/ State IV-D Contact Address

____ Use Local Return Address/ Local Contact Address

____ Use State IV-D Return Address/ Local Contact Address

____ N/A; our State issues its own Pre-Offset Notice

FMS Offset Notice:

____ Use State Contact Address

____ Use Local Contact Addresses

State IV-D Address:

All States must provide a State IV-D address, whether or not Local addresses are used.

(Please note that the State IV-D address indicated below may be used as the contact information included in one or both of the notices sent).

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Telephone: (______) _______ - ___________________________

Telephone 2 (Optional): (______) _______ - _________________

How long does your State want OCSE to hold new cases from the Pre-Offset Notice date before forwarding to FMS for offset certification?

___ 30 days

___ 45 days

___ 60 days

___ 90 days

Signature of IV-D Director or Designee _______________________________

Agency Contact __________________________________________________

Agency Contact's Phone Number ____________________________________

Agency Contact’s E-Mail Address ___________________________________

The Paperwork Reduction Act of 1995

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a currently valid OMB control number. This information collection is expected to take .4 hours per response. OMB control number: 0970-0161, Expiration date 4/30/2007.