Form OCSE 21-U4 OCSE 21-U4 State Plan Transmittal Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Control No: 0970-0017

OFFICE OF CHILD SUPPORT SERVICES Expiration date: XX/XX/202X

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: TITLE IV-D OF THE SOCIAL SECURITY ACT	TRANSMITTAL NUMBER	STATE
	ACTION TRANSMITTAL NUMBER AND DATE
TO: REGIONAL REPRESENTATIVE OFFICE OF CHILD SUPPORT SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES REGION ____________________________________	PROPOSED EFFECTIVE DATE
TYPE OF PLAN MATERIAL (Check One)  NEW STATE PLAN  AMENDMENT TO BE CONSIDERED AS A NEW PLAN  AMENDMENT  MANDATORY STATE LAW AND PROCEDURES EXEMPTION REQUEST AMENDMENT
COMPLETE NEXT 4 BLOCKS IF THIS IS AN AMENDMENT
FEDERAL REGULATION CITATION
NUMBER OF THE PLAN SECTION OR ATTACHMENT	NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT
SUBJECT OF AMENDMENT
GOVERNOR’S REVIEW (Check One)  GOVERNOR’S OFFICE REPORTED NO COMMENT  OTHER, AS SPECIFIED:  COMMENTS OF GOVERNOR’S OFFICE ENCLOSED  NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
SIGNATURE OF STATE AGENCY OFFICIAL (Electronic signature acceptable)	FOR REGIONAL OFFICE USE ONLY
	DATE RECEIVED	DATE APPROVED
TYPED NAME:	PLAN APPROVED – ONE COPY ATTACHED
	EFFECTIVE DATE OF APPROVED MATERIAL
TITLE:	SIGNATURE OF REGIONAL OFFICIAL
DATE OF SUBMITTAL:	TYPED NAME:
RETURN TO:	TITLE:
	REMARKS:

FORM OCSS-21-U4

The Paperwork Reduction Act of 1995 (Pub. L. 104-13) Statement of Public Burden: The purpose of this information collection is to provide uniformity and standardization in the transmission of interstate administrative subpoenas. Public reporting burden for this collection of information is estimated to average .25 hours per form, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required for interstate cases (section 454(9)(E) of the Social Security Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0017 and the expiration date is XX/XX/202X. If you have any comments on this collection of information, please contact OCSS by email at [email protected].