Form 1 Annual Certification Letter

Annual Certification Letter

Use State Letterhead

Date:

Office of Child Support Enforcement

Department of Health and Human Services

Federal Collections and Enforcement

330 Independence Avenue, SW

Room G-644

Washington, DC 20201

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 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 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 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 party attesting to the amount of support owed and has, in non-assistance cases, the custodial party’s current, or last known, address.

3. The Pre-Offset Notice that we will issue to the noncustodial parent meets the requirements set forth in the regulations, or the address information provided for the noncustodial 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 support owed owed by the individual exceeds or has exceeded $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 party attesting to the amount of support owed.

3. The Pre-Offset Notice that we will issue to the noncustodial parent meets the requirements set forth in section 454(31) of the Act, or the address information provided for the noncustodial 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 is delinquent.

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 OCSE Pre-Offset Notice:

We request that OCSE mail Pre-Offset Notices to noncustodial parents.___Yes_____No

If yes, which address type should be used on your State’s 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

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

State IV-D Address:

All States must provide a State IV-D address and contact information. The State IV-D address below may be used in the OCSE-issued Pre-Offset Notice and/or the Fiscal Service Offset Notice.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Telephone: (______) _______ - ___________________________

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

How long does your State want OCSE to hold new cases from the Pre-Offset Notice date before forwarding to Fiscal Service 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(Pub.L. 104-13)

Public reporting burden for this collection of information is estimated to average 0.4 hours, per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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.

Federal Collections & Enforcement Annual Certification Letter OMB 0970-0161 Expiration Date: xx/xx/xxx