Form 1 Registration Statement

REGISTRATION STATEMENT
Responding IV-D Case Identifier
Responding Tribunal Number
Initiating IV-D Case Identifier
Initiating Tribunal Number
Action:

[
[

] Register for Enforcement
] Register for Modification

I. Case Summary (Background of this Matter: Court / Administrative Actions)
Date of Support Order

State and County Issuing Order

Support Amount/Frequency

Date of Last Payment

Tribunal Case Number

Amount of Arrears
$

$

Period of Computation
thru
Date

[ ] Tribunal Has Determined This to Be Controlling Order
[ ] Only Order
II. Mother Information
[ ] Obligor
[ ] Obligee
Full Name
Address (Street, City, State, Zip)
(first, middle, last)

Date

Employer (Name, Street, City, State, Zip)

Aliases, Maiden Name
Social Security Number:
III. Father Information
Full Name
(first, middle, last)

[ ] Obligor
[ ] Obligee
Address (Street, City, State, Zip)

Employer (Name, Street, City, State, Zip)

Aliases
Social Security Number:
IV. Caretaker (If Not a Parent)
Full Name
(first, middle, last)

Relationship to Child(ren)

[

] Has legal custody/guardianship of child(ren)

Address (Street, City, State, Zip)

Aliases
Social Security Number:
V. Additional Case Information
[ ] Nondisclosure Finding Attached
This order is registered in the following states:
Description and location of any property not exempt from execution:

Other:

VI. Verification / Certification
Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my
knowledge and belief.

Date

Sworn to and Signed Before Me This
Date, County/State

Registration Statement

[

] Party Seeking Registration

[

Notary Public, Court/Agency Official and Title

] Records Custodian

Commission Expires

OMB 0970 – 0085 Expiration Date: 01/31/2014

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INSTRUCTIONS FOR REGISTRATION STATEMENT
PURPOSE OF THE FORM:
The Registration Statement is completed by the initiating jurisdiction to request registration of an existing order for
enforcement and/or modification. The purpose of the form is to refer specific order information to the responding State.
This form can be used in IV-D and non-IV-D interstate cases. It should be included with the other appropriate forms and
directed to the responding State’s central registry. In non-IV-D cases, contact the responding State central registry to
determine appropriate procedures. It is important to remember that a separate Registration Statement is needed for each
order that the initiating State is requesting be registered by the responding State.

Italicized text that appears within a “box” refers to policy or provides additional information.
HEADING/CAPTION:
• In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction’s IV-D case identifier, and

Tribunal number.
Under “IV-D case identifier”, 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. Under “tribunal number”, you may enter the docket number,
cause number, or any other appropriate reference number that the responding State may use to identify the
case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the

initiating jurisdiction.
• In the appropriate spaces, enter the Initiating jurisdiction’s IV-D case identifier, and tribunal number.

Under “IV-D case identifier”, 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. Under “tribunal number”, you may enter the docket number,
cause number, or any other appropriate reference number which the initiating tribunal or agency has assigned
to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for
services.

ACTION:
Check the appropriate box indicating whether you are registering this order for enforcement or modification. NOTE
that registration for enforcement should be accompanied by Transmittal #1. Registration for modification should be
accompanied by Transmittal #1, Uniform Support Petition, and General Testimony.

SECTION I, CASE SUMMARY:
Provide complete information for all court/administrative actions regarding support for dependents. Use a separate
Registration Statement form for each court/administrative order you are requesting be registered. For the listed order,
under “Period of Computation”, enter the month, day, and year for both the beginning of the current support obligation
and the end date of the computation. The information in this section will be used to aid in verifying calculated arrearages
and to assist in determining/verifying which order is controlling and which State has continuing exclusive jurisdiction.
The arrears statement/payment history must support this calculation. If this order was determined by a tribunal to be the
controlling order, check the appropriate box. If this is the only order, check “Only order”.
Attach the required number of copies of all pertinent orders that relate to support. You will generally need to attach two
copies, one of which is certified, of any support order. NOTE, however, that some responding States may be able to take
certain administrative enforcement actions (e.g., interstate income withholding) without having a certified copy of the
order, although a regular copy is necessary.

SECTION II, MOTHER INFORMATION:
This section provides basic information about the child(ren)’s mother. Check the appropriate box to indicate if the mother
is the obligor or obligee. Provide the mother’s full name (first, middle, last) as well as aliases and maiden name, and all
other information. Provide the name and full address of the mother’s employer. If the mother’s name does not match with
the court or administrative order, explain in Section V. If a nondisclosure finding exists, do not enter the mother’s
address/identifying information on the form; you may enter a substitute address.

Instructions for Registration Statement

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SECTION III, FATHER INFORMATION:
This section provides basic information about the child(ren)’s father. Check the appropriate box to indicate if the father is
the obligor or obligee. Provide the father’s full name (first, middle, last) as well as aliases, and all other information.
Provide the name and full address of the father’s employer. If the father’s name does not match with the court or
administrative order, explain in Section V.

SECTION IV, CARETAKER (IF NOT A PARENT):
Complete this section only if the child(ren)’s caretaker is not the child(ren)’s parent. In the space labeled “Relationship to
Child(ren)”, indicate the relationship of the caretaker to the child(ren). Provide the caretaker’s full name (first, middle, last) as
well as aliases or maiden name, and all other information. Indicate whether the caretaker has legal custody/ guardianship of
child(ren), if known.

SECTION V, ADDITIONAL CASE INFORMATION:
In this section, provide additional information which may be useful to the responding jurisdiction in working the case, such
as a complete listing of all States where the child support order has previously been registered and a description,
including the location, of all known property or assets not exempt from execution. In addition to the requested information,
use this portion of the form to provide other information which may assist the responding jurisdiction in its efforts to
register the order.

SECTION VI, VERIFICATION/CERTIFICATION:
 The Registration Statement may be signed by either the party seeking registration or an authorized IV-D

representative/records custodian. Check the appropriate box to indicate who has signed this form.


The verification signature requires a notary

The Paperwork Reduction Act of 1995
This information collection is conducted in accordance with 42 U.S.C. 651 et seq. and 45 CFR 303.7 of the child
support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate
case processing. Public reporting burden for this collection of information is estimated to average under half an
hour per response. The responses to this collection are mandatory in accordance with the above statute and
regulation. This information is subject to State and Federal confidentiality requirements; however, the information
will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed
to other parties. 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.

Instructions for Registration Statement

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