Form 1 Child Support Agency Confidential Information

CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM
FOR IV-D AGENCY USE ONLY – DO NOT FILE WITH A TRIBUNAL OR PROVIDE TO THE OTHER PARTY
The information on the form may be disclosed only as authorized by law.
If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution, or copying of this form
or its contents is strictly prohibited.

NOTE:

[ ] This form sent through EDE

Section I. Case Information:
Initiating jurisdiction name:

Responding jurisdiction name:

Initiating IV-D case identifier:

Responding IV-D case identifier:

Initiating tribunal number:

Responding tribunal number:

Section II. Parent/Caretaker Information:
Parent

[ ] Obligee or [ ] Obligor

Parent

[ ] Obligee or [ ] Obligor

Legal name (first, middle, last, suffix):

Legal name (first, middle, last, suffix):

Relationship to child(ren):

Relationship to child(ren):

Gender: [ ] Male

[ ] Female

[ ] Other

Date of birth:

Gender: [ ] Male

[ ] Female [ ] Other

Date of birth:

Place of birth:
(city, county, state)

SSN:

Home telephone:

Cell telephone:

Work telephone:

Place of birth:
(city, county, state)

SSN:
Cell telephone:

Home telephone:
Work telephone:

Alias (e.g., maiden name, nickname):

Alias (e.g., maiden name, nickname):

Home address (street, city, state, zip code):

Home address (street, city, state, zip code):

Date address confirmed: ___________________

Date address confirmed: ___________________

Mailing address (street, PO Box, city, state, zip code):

Mailing address (street, PO Box, city, state, zip code):

Date address confirmed: ___________________

Date address confirmed: ___________________

E-mail:

E-mail:

Employer name:

Employer name:

Date employer confirmed: __________________

Date employer confirmed: __________________

Employer address (street, city, state, zip code):

Employer address (street, city, state, zip code):

Employer FEIN:

Employer FEIN:

Incarcerated? [ ]Yes [ ] No

Incarcerated? [ ]Yes [ ] No

(If yes, Inmate #: ________________________________________ (If yes, Inmate #: _________________________________________
and facility name:_______________________________________) and facility name: ________________________________________)

Child Support Agency Confidential Information Form

OMB 0970 – 0085

Expiration Date: XX/XX/XXXX

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CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM, PAGE 2

Caretaker - Obligee (When obligee is not the child(ren)’s parent)
Legal name (first, middle, last, suffix):
Relationship to child(ren):
Gender: [ ] Male

[ ] Female [ ] Other

Date of birth:
SSN:

Home telephone:

Cell telephone:

Work telephone:

Home address (street, city, state, zip code):
Date address confirmed: ___________________
Mailing address (street, PO Box, city, state, zip code):
Date address confirmed: _____________________
E-mail:

Section III. Child(ren) Information:
Child #1 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):
SSN:

Date of birth:

Place of birth (city, county, state):

Gender: [ ] Male

Nonmarital birth:

[ ] Yes

[ ] Female

[ ] No (If no, date of marriage: _________________________)

If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ___________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.

Child Support Agency Confidential Information Form

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CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM, PAGE 3
Section III. Child(ren) Information (Continued):
Child #2 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):

SSN:
Place of birth (city, county, state):

Nonmarital birth:

[ ] Yes

Date of birth:
Gender: [ ] Male

[ ] Female

[ ] No (If no, date of marriage: _________________________)

If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ____________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.
Child #3 legal name (first, middle, last, suffix):
Home address (street, city, state, zip code):

SSN:
Place of birth (city, county, state):

Nonmarital birth:

[ ] Yes

Date of birth:
Gender: [ ] Male

[ ] Female

[ ] No (If no, date of marriage: _________________________)

If yes, complete the following:
[ ] Parentage established. Was this parentage establishment a paternity determination of fatherhood? [ ] Yes [ ] No
Parentage was established on _______________________ (date) in ____________________________ (state).
Parentage was established by:
[ ] Order
[ ] Acknowledgment of Parentage
[ ] Adoption
[ ] Other: _________________________________________________________________
[ ] Parentage was not established.

[ ] Additional Child(ren) Information Attached
Encryption Requirements:
When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data.
Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support
Enforcement. Other electronic means, such as encrypted attachments to e-mails, may be used if the encryption method is
compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

Child Support Agency Confidential Information Form

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INSTRUCTIONS FOR CHILD SUPPORT AGENCY CONFIDENTIAL INFORMATION FORM
PURPOSE OF THE FORM:
This form is for Child Support (IV-D) Agency use only and is not to be filed with a tribunal or provided to the other
party. The Child Support Agency Confidential Information Form is intended to safeguard the privacy of individuals by
providing a means to record their personal identifiable information on a separate document that is not served on the
parties or filed with a tribunal. The information contained in the form is governed by federal and state safeguarding
and privacy requirements.
Italicized text that appears within a “box” refers to policy or provides additional information.

For an address outside the United States, be sure to include the foreign country and postal code.

Tribal IV-D programs may choose to use the federal Intergovernmental forms. However, they are not required to
use or accept such forms. If you have any questions, contact the tribal IV-D agency directly using the contact
information on the OCSE website.
Where forms request a locator code, note that tribal locator codes uniquely identify tribal cases with “9” in the first
position, 0 (zero) in the second position, and then a 3-character tribal code defined by the Bureau of Indian Affairs
(BIA).
In the “NOTE:” section, check any of the following that apply:
•
This form sent through EDE – Check if this form was sent through the Electronic Document Exchange
(EDE).
The following options are available for making IV-D requests and sending information on IV-D cases:
1. CSENet transactions are the recommended method for making requests or sending information to another
state. If CSENet is not listed as an option on the form, then it cannot be used to convey any of the requests
for information or IV-D requests provided on the form. Supporting documentation should be sent through
EDE, whenever possible. If certified copies are needed, hard copies should also be sent by mail. Mail or fax
may also be used for all documents when EDE is not available.
2. If CSENet transactions are not available in your state, EDE is the next preferred method for transmitting your
request or information. Both your state and the receiving state must be using the EDE application to use this
communication method.
3. If the EDE application is not available in your state or the receiving state, then mail or fax must be used to
communicate your request.

Section I. Case Information
In the space provided, enter:
•
Initiating jurisdiction name
•
Initiating IV-D case identifier
•
Initiating tribunal number
•
Responding jurisdiction name
•
Responding IV-D case identifier, if known
•
Responding tribunal number, if known
The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services. The
responding jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction. Under
“IV-D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case Registry, which
is a left-justified up to 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 initiating and responding tribunals have assigned to the case.

Child Support Agency Confidential Information Form Instructions

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Section II. Parent/Caretaker Information:
Identify each parent as the obligee or obligor, as appropriate. UIFSA defines obligor to include a person alleged to be
a parent. For each parent, enter:
• Full legal name (first, middle, last, suffix)
• Relationship to the child(ren)
• Gender*
• Date of birth
• Place of birth (city, county, state or the foreign country of birth)
• Social Security Number
• Home telephone number
• Cell telephone number
• Work telephone number
• Any known alias (e.g., maiden name, nickname) - an alias may include a person’s former married name.
• Home address (street, city, state, zip code) - include all parts of the address (e.g., apartment number)
• Date home address was confirmed
• Mailing address (street, PO Box, city, state, zip code) - include all parts of the address (e.g., apartment
number)
• Date mailing address was confirmed
• E-mail address that parent prefers for communication
• Employer’s name
• Date employer was confirmed
• Employer’s address (street, city, state, zip code) - include all parts of the address (e.g., suite number)
• Employer Federal Employer Identification Number (FEIN)
• Whether person is Incarcerated:
• If “No,” continue completion of the form.
• If “Yes,” enter the Inmate number, if known, and facility name, if known
Complete the caretaker-obligee information only if the child(ren)’s caretaker is someone other than the child(ren)’s
parent. Enter the following information about the caretaker-obligee:
• Full legal name (first, middle, last, suffix)
• Relationship to the child(ren)
• Gender*
• Date of birth
• Social Security Number
• Home telephone number
• Cell telephone number
• Work telephone number
• Home address (street, city, state, zip code) - include all parts of the address (e.g., apartment number)
• Date home address was confirmed
• Mailing address (street, PO Box, city, state, zip code) - include all parts of the address (e.g., apartment
number)
• Date mailing address was confirmed
• E-mail address that caretaker-obligee prefers for communication
* Gender is defined as "male," "female," or "other". Select "other" if the person does not identify as "male" or
"female."

Child Support Agency Confidential Information Form Instructions

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Section III. Child(ren) Information:
Identify all of the children for whom support is owed or being sought. For each child, enter:
• Full legal name (first, middle, last, suffix)
• Home address (street, city, state, zip) - include all parts of the address (e.g., apartment number)
• Social Security Number
• Date of birth
• Place of birth (city, county, state or the foreign country of birth)
• Gender
• Whether this was a nonmarital birth (parents were not married when child was born, also referred to as “born
out of wedlock” or BOW)
• If “No”, enter the date of the marriage.
• If “Yes”, this is a nonmarital birth, complete the information below.
o Check "Parentage established" if parentage has already been established (the legal parent-child
relationship between a child and unmarried parents has been determined). Check the appropriate
box to indicate whether the parentage establishment was a paternity determination of fatherhood.
“Paternity” is defined as the legal establishment of fatherhood for a child, either by court
determination, administrative process, or voluntary acknowledgment.
• Enter the date parentage was established and the state in which parentage was established.
• Identify how parentage was established - by order of a tribunal, by acknowledgment of
parentage, by adoption, or by other legal process under state law. If “Other,” describe how the
parent-child relationship was established
o

Check “Parentage not established” if parentage has not been established.

Check “Additional Child(ren) Information Attached” when support is owed or being sought for more than three
children or if additional space is needed.

Encryption Requirements:
When communicating this form through electronic transmission, precautions must be taken to ensure the security of the
data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child
Support Enforcement. Other electronic means, such as encrypted attachments to e-mails, may be used if the encryption
method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

The Paperwork Reduction Act of 1995
Public reporting burden for this collection of information is estimated to average 0.05 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.

Child Support Agency Confidential Information Form Instructions

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