Form 1 Subpoena

Administrative Subpoena
TO:
(Name, address)

Regarding:
(name, DOB, SSN)

Case Caption:
FROM:
(CSE Agency, address, phone, e-mail address, fax number)
IV-D Case Number:

Under Federal law (42 U.S.C. 666(c)(1)(B)) and similar statutes in this and all other
States, you are required to provide financial or other information needed to establish,
modify, or enforce a child support order.
Provide the following information or documents by ______________:
(Date)

The information or documents may be mailed or faxed. Your response to this subpoena
must be dated, signed by you or your designee, and be either [ ] notarized OR [ ]
witnessed with the following statement:
“I declare (or certify, verify, or state) under penalty of perjury that the foregoing
is true and correct. Executed on (date).”
As an authorized agent of a State or county agency responsible for implementing the
child support enforcement program set forth in Title IV, Part D, of the Federal Social
Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have
effect in any State. Failure to obey this subpoena may result in the imposition of
penalties, including fines or imprisonment, as provided under the laws of your State. For

Page 1 of 2

additional information regarding this subpoena, including how to challenge it, please
contact the issuing agency and reference the IV-D case number.

___________
Date

____________________________________
Authorized Agent
____________________________________
Print name, e-mail address, phone number
and fax number

Notice: Respondents are not required to respond to this information collection unless it displays a valid
OMB control number. The average burden for responding to this information collection is estimated at 30
minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please
provide comment to the issuing agency.
OMB Control # 0970-0152 Expiration Date: 01/31/2008

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Administrative Subpoena
TO:

(1)

(Name, address)

Regarding:

(2)

(name, DOB, SSN)

Case Caption:

(3)

FROM: (4)
(CSE Agency, address, phone, e-mail address, fax number)
IV-D Case Number:

(5)

Under Federal law (42 U.S.C. 666(c)(1)(B)) and similar statutes in this and all other
States, you are required to provide financial or other information needed to establish,
modify, or enforce a child support order.
Provide the following information or documents by _______(6)_______:
(Date)
(7)

The information or documents may be mailed or faxed. Your response to this subpoena
must be dated, signed by you or your designee, and be either [(8) ] notarized OR [(8) ]
witnessed with the following statement:
“I declare (or certify, verify, or state) under penalty of perjury that the foregoing
is true and correct. Executed on (date).” (9)
As an authorized agent of a State or county agency responsible for implementing the
child support enforcement program set forth in Title IV, Part D, of the Federal Social
Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have
effect in any State. Failure to obey this subpoena may result in the imposition of
penalties, including fines or imprisonment, as provided under the laws of your State. For

additional information regarding this subpoena, including how to challenge it, please
contact the issuing agency and reference the IV-D case number.
___________
Date

____________________________________
Authorized Agent (10)
____________________________________
Print name, e-mail address, phone number
and fax number (11)

Notice: Respondents are not required to respond to this information collection unless it displays a valid
OMB control number. The average burden for responding to this information collection is estimated at 30
minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please
provide comment to the issuing agency.
OMB Control # 0970-0152 Expiration Date: 03/31/2004

Instructions for the Administrative Subpoena
Purpose of this form: The Administrative Subpoena is the Federal form that the State IVD programs, pursuant to section 454(9)(E) of the Social Security Act, are required to use
in interstate cases. A State may elect to use this form in intrastate cases. This form is to
be administratively issued by the IV-D program to subpoena financial or other
information needed to establish, modify, or enforce a child support order.
To complete this form:
1. Place in the “TO” field the name and address of the individual or entity on whom you
are serving the subpoena. (Frequently, this will be an employer.)
2. Place in the “REGARDING” field the name, date of birth, and SSN (if available) of
the individual you are requesting information about. (Frequently, this will be the
noncustodial parent.)
3. Place in the “CASE CAPTION” field the title of the proceeding (i.e., John Doe v.
Jane Doe), under which you are issuing the subpoena.
4. Place in the “FROM” field Child Support Enforcement Agency name, address, phone
number, e-mail address and fax number.
5. For IV-D Case Number, 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.
6. Provide the date that the requested documents are to be provided to you.
7. Clearly, completely, and specifically describe all records or documents that you are
requesting the individual receiving the subpoena provide.
8. Depending on your State law, check either the “NOTARIZED” box if you require
notarized documents OR the “WITNESSED” box.
9. Place the date the subpoena is signed in the “DATE” field.
10. The person issuing the subpoena signs in the “AUTHORIZED AGENT” field.
11. Print name, e-mail address, phone number and fax number.