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
Mary E. Switzer Building
330 C Street, SW, 5th Floor
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.

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

I certify that every request for passport denial meets the following requirements:
1. The amount of support owed owed by the individual exceeds $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

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

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 Bureau of 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 the Bureau of the 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
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. This information
collection is expected to take .4 hours per response. OMB control number: 0970-0161,
Expiration date .

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