Form OCSE-100 State Plan Cover Page

OCSS-100 OMB 0970-0017

Expiration Date Month XX, 202X

STATE PLAN FOR SUPPORT COLLECTION AND ESTABLISHMENT OF PATERNITY UNDER TITLE IV-D OF THE SOCIAL SECURITY ACT

STATE

As a condition to the receipt of Federal funds under title IV-D of the Social Security Act, the

(name of single & separate IV-D agency)

submits herewith the State plan for the program of support collection and establishment of paternity under title IV-D of the Act and hereby agrees to administer the program in accordance with the provisions of this State Plan, the Act, and all applicable Federal Laws, regulations and other official issuances of the Department.

The official text of said laws, regulations, and official issuances govern and the State agency acknowledges its responsibility to adhere to them.

TN # Approval Date Effective Date

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 .50 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].