Form 1 Debt Inquiry Services Insurer Agreement and Profile Form

OMB Control No: 0970-0370
Expiration Date: MM-DD-YYYY

Department of Health and Human Services
Administration for Children and Families
Office of Child Support Enforcement

Debt Inquiry Service Insurer Agreement and Profile
Description of Service
After completing the registration process and receiving your activation code, you can access the
Portal to:
1. Report lump sum or claim payments for claimants who may owe past-due child support.
2. Register as a third-party insurer if you report claim information for more than one
insurance company and use multiple FEINs.

Instructions
Fill out all the required fields in this form and email it to the Portal Help Desk. One of our team
members may contact you if additional information is necessary to complete the registration
process.

Disclaimer
By completing and supplying the information in this form, you agree to:
1. Not impersonate any individual, entity, or association; conceal; or supply misleading
information about my identity while transmitting files.
2. Supply true, accurate, current, and complete information about the entity identified in
this form.
3. Not use any information obtained as a result of involvement with Debt Inquiry for
employment decisions.
By selecting Accept, you certify that you have read, understood, and agree to the terms of this
agreement.

Accept

Decline

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Debt Inquiry Profile
Required *

General Information
Enter general information about your organization and participation in the Debt Inquiry Service.
Date: *
(MM/DD/YYYY)

FEIN: *
(Primary Federal Employer Identification Number Format: 123456789)

Organization Type: *
(Select Third Party if reporting claims for multiple FEINs.)

Organization Name: *

Organization Short Name:
(Enter abbreviation for your organization. Maximum 25 characters.)

Address Information
Is this the address where child support agencies should send liens/levies?

Yes

No

Address Line 1: *

Address Line 2:

Address Line 3:

City: *

State: *

ZIP Code (5 digits): *

ZIP Code Ext:

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Required *

Contact Information
Enter business, technical, and debt inquiry contact information.

Business Contact Information
Contact Name: *

Contact Phone Number: *
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Email: *
(Format: [email protected])

Select if you want email notifications sent to this address.

Technical Contact Information
A network or system administrator who can help provide corporate IP address information or batch system
information, if applicable.
Contact Name:

Contact Phone Number:
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Email:
(Format: [email protected])

Select if you want email notifications sent to this address.

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Debt Inquiry Contact Information
Enter information for the person in your organization child support agencies should contact if they have questions about the
matches.
Contact Name: *

Contact Phone Number: *
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Fax:
(Enter numeric characters only, including area code. Format: 1231231111)

Contact Email: *
(Format: [email protected])

Select if you want email notifications sent to this address.

Communication Preference
You must select a preferred method of communication for your organization: email, fax, or phone.

Communication Preference: *

File Information
Your organization must submit Debt Inquiry Payout files as .csv, .txt, .xls, and .xlsx files only. File names must start with 'FEIN.
DI.'. The file names must only contain alphanumeric characters, with no special characters, such as parentheses, or spaces. If
your organization submits multiple files on one day, each file name must be unique. A suggested approach is to append a
date and a sequence number to the file name. (Example: 123456789.DI.06092012.33.xlsx)
We will only process files if your organization has a profile and one registered user in the system.

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File Encryption:
If you choose file encryption, your organization must use OCSE's GPG public key to encrypt files destined for OCSE. The OCSE
Portal network administrator will email the key to you. OCSE will need your organization's GPG or PGP public key if files
destined for your organization require encryption.
Encrypt File? *
Yes

No

Transmission Method:
Choose how Debt Inquiry Payout files will be transferred to OCSE.

Method of Transmission: *
Debt Inquiry web application
Partner will send to OCSE
OCSE will retrieve from partner

IP Address Information
The federal Office of Child Support Enforcement (OCSE) requires a public Internet Protocol (IP) address from external
partners to allow secure access to the Child Support Portal. OCSE independently verifies the IP address and organization
name with the American Registry for Internet Numbers (ARIN), a regional internet registry for the United States. For more
information, visit the ARIN website.
Enter the public IP addresses your organization uses to access the internet. In most cases, the IP address is your company's
internet proxy server or the public IP address of the computer used to access OCSE's Child Support Portal. To locate your
public IP address, search on the internet for "What Is My Public IP Address." You must verify the addresses with your
network administrator.
Public IP Addresses: *

By completing this section, you certify your organization holds exclusive use of the static IP addresses assigned by an
Internet Service Provider vendor. If the static IP address assigned to your organization changes, you must contact the
Portal Help Desk.

Name of Internet Service Provider: *

(Example: Comcast, AT&T, or Verizon. Enter your
company name if you own your IP address and it is
verifiable on ARIN website.)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub.L. 104-13):
Public reporting burden for this collection of information is estimated to average 0.08 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.

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