Form 1 Tracking the $25 fee

OMB Control No: 0970-0017

Expiration date: 11/30/2007

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OFFICE OF CHILD SUPPORT ENFORCEMENT Submit 2 Copies

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: TITLE IV-D OF THE SOCIAL SECURITY ACT	TRASNMITTAL NUMBER	STATE
	ACTION TRANSMITTAL NUMBER AND DATE
TO: REGIONAL REPRESENTATIVE OFFICE OF CHILD SUPPORT ENFORCEMENT DEPARTMENT OF HEALTH AND HUMAN SERVICES REGION ____________________________________	PROPOSED EFFECTIVE DATE
TYPE OF PLAN MATERIAL (Check One)  NEW STATE PLAN  AMENDMENT TO BE CONSIDERED AS A NEW PLAN  AMENDMENT
COMPLETE NEXT 4 BLOCKS IF THIS IS AN AMENDMENT
FEDERAL REGULATION CITATION
NUMBER OF THE PLAN SECTION OR ATTACHMENT	NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT
SUBJECT OF AMENDMENT
GOVERNOR’S REVIEW (Check One)  GOVERNOR’S OFFICE REPORTED NO COMMENT  OTHER, AS SPECIFIED:  COMMENTS OF GOVERNOR’S OFFICE ENCLOSED  NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
SIGNATURE OF STATE AGENCY OFFICIAL (1 Original signature required)	FOR REGIONAL OFFICE USE ONLY
	DATE RECEIVED	DATE APPROVED
TYPED NAME:	PLAN APPROVED – ONE COPY ATTACHED
	EFFECTIVE DATE OF APPROVED MATERIAL
TITLE:	SIGNATURE OF REGIONAL OFFICIAL
DATE OF SUBMITTAL:	TYPED NAME:
RETURN TO:	TITLE:
	REMARKS:

FORM OCSE-21-U4