![](media/image1.png)![](media/image2.png){width="1.7in"
height="1.1430555555555555in"}

**INDICATOR NAME:** Family Violence Indicator

**SETTING CRITERIA:** [IV-D]{.underline}

Good Cause request or status (TANF \-- Family violence basis)

[IV-D (Non-TANF) & Non IV-D]{.underline}

Self-report (Written)

**ELIGIBLE PEOPLE:** [People Directly Protected]{.underline} \--

Victims

[Others Protected]{.underline} \--

All children involved in the victim's RI child support cases or orders
with abuser (Automatic)

**IMPACT:** [Overall]{.underline}\--

Sends FV Indicator to the FCR

[IV-D]{.underline}

Results in referral to county attorney for additional protection and
safety planning (includes motion to seal court file(s))

Prompts greater care by agency

Will delete addresses from agency documents, including court filings
(future)

Will make victim's data available only to responsible staff (future)

Will prompt screen warnings (future)

**DURATION:** Indefinite

**REMOVAL CRITERIA:** Victim request

**OVERRIDE:** Preliminary procedure in place/draft available

*The policy statement that appears below explains how to set the Family
Violence Indicator in Rhode Island. Also, the pages that follow set out
the attachments referenced in the policy statement. (On screen samples,
the family violence data element appears in **bold**.)*

# 

# SPECIFICATIONS FOR CSE WELFARE REFORM CHANGE ORDER

*Add a Family Violence Indicator to the IV-D Case*

To accommodate the Federal Case Registry (FCR) requirement that . . .
family violence be indicated on each person added to the FCR for whom it
is appropriate, it is proposed to add such an indicator to the IV-D
system. This indicator would be used in addition to good cause and would
be especially useful on bookkeeping cases and for those cases without
good cause where there is a perceived or real threat to the client
and/or the children.

**[SETTING THE FAMILY VIOLENCE INDICATOR]{.underline}**

[APPD/E mode:]{.underline}

A new field for entry of the family violence indicator will be added to
the NCAS screen. Valid values will be "Y" or "N" only. This field may
not be left blank. Note: A family violence field has already been added
to the CSS-1. See Attachment A.

[BGBH Interface:]{.underline}

The family violence indicator will be automatically set to "Y" when
\[the\] good cause basis is one of the following values regardless of
whether determination is "D" (denied):

A Physical harm to the child

B Emotional harm to the child

C Physical harm to the parent which reduces his/her capacity to
adequately care for the child

D Emotional harm to the parent which reduces his/her capacity to
adequately care for the child

E Anticipated physical harm to the parent or child without corroborative
evidence

F The child was conceived as a result of incest or of forcible rape

I Family violence (future value)\[.\]

The family violence indicator will be automatically set to "N" when
\[the\] good cause basis is one of the following values:

G Legal proceedings for adoption are pending before a court of competent
jurisdiction

H Parent receiving pre-adoption services

Space No basis is claimed\[.\]

Setting of this new indicator will in no way affect the current logic
surrounding the setting of the service level to and from "G" (good
cause).

[APPD/CASE:]{.underline}

A new field for entry and display of the family violence indicator will
be added to the case screen. Valid values will be "Y" or "N" only. This
field cannot be changed to a blank. If good cause basis is "A" - "F" or
"I" and this field is changed to "N" a warning will be displayed:
"WARNING: CLIENT MAY STILL HAVE A THREAT OF PHYSICAL/EMOTIONAL HARM".
See Attachment B.

**[DISPLAYING THE FAMILY VIOLENCE INDICATOR]{.underline}**

The family violence indicator will be available for display on the
following panels:

APPD/CHLD \-- Attachment C

APPD/CLNT \-- Attachment D

COMM \-- Attachment E

ACAS \-- Attachment F

CCAS \-- Attachment G\[.\]

**[TRACKING CHANGES TO THE FAMILY VIOLENCE INDICATOR]{.underline}**

As with other indicators and flags, changes to the family violence
indicator will be tracked. The change will include who made the change,
change from and to values and will be available in TRAC/Contacts and
Comments. See Attachment H.

**[USE OF THE FAMILY VIOLENCE INDICATOR WITHIN THE SYSTEM]{.underline}**

[FORM:]{.underline}

Access to the FORM function will be allowed for cases with the family
violence indicator equal to "Y". However, a warning will be displayed:
"WARNING: CASE IS FLAGGED FOR FAMILY VIOLENCE". See Attachment I.

[FCR INTERFACE:]{.underline}

This field will be the basis for setting the family violence indicator
on an add or change person transaction sent to the FCR. If the value of
the indicator on the case is "Y", the family violence field for the
client and all the children will be set to "Y".

[Legal Unit Form:]{.underline}

If the family violence indicator is "Y", the text "\*FAMILY VIOLENCE\*"
will print next to the title "CLIENT DATA". If the family violence
indicator is "N", the above test will not print. See Attachment J.

[CSENet Quick Locate Provides:]{.underline}

If a person for whom a quick locate has been received is found on the
InRhodes database and is also found as a client or child on at least one
IV-D case where the family violence indicator is "Y", the system will
provide a response of "LUALL" (no information found).

**[CONVERSION:]{.underline}**

Each case will be processed. For closed and responding cases\[,\] the
family violence indicator will be set to "N". For all other cases, the
last STAT/ABSP panel will be examined. If the good cause basis on this
panel is "A" - "F" or "I" (regardless of the value of good cause
determination), the family violence indicator will be set to "Y". If the
good cause basis is "G" - "H" or space or no STAT/ABSP panel is found,
the indicator will be set to "N". A report of all cases in which the
indicator is set to "Y" and the service level is not "G" will be
produced.

If this indicator is put in place following the initial load of cases to
the FCR, the conversion will also need to create change person trigger
records for those cases on which the service level is not "G", but the
family violence indicator is now a "Y".

## DRAFT SPECIFICATIONS \-- FAMILY VIOLENCE INDICATOR

**Attachment A**

AP ON FILE - ENTER CLIENT DATE OR CANC

xx/xx/xx xx:xx NEW CASE DATA xxxx xxxxxxx

xxxxxxx NCAS xxxx xxxxxxx

SERVICE **FAMILY** DATE APPLICATION

TYPE LEVEL **VIOLENCE** REQUESTED SENT RECEIVED

\_\_ \_\_\_- F \_\_\_ \_\_ \_\_ \_\_\_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_
\_\_\_ \_\_\_ \_\_\_\_\_

BIRTH DATE

SSN LAST FIRST M MOD MM DD YYYY S ETH

ABSENT PARENT: xxx xx xxxx DOE JOHN Q xx xx xxxx M \--

CLIENT: xxx xx xxxx DOE JANE Q xx xx xxxx F \--

OTHER ABSENT PARENT CASES

CASE NO CASE TYPE CLIENT SSN CLIENT NAME

\*\*\*\* NO CASES \*\*\*\*

RL: XX XX ABSP: XXX XX XXXX CMD:

FNX: APPD E CLIENT: PNL:

**Attachment B**

xx/xx/xx xx:xx CASE STATUS DATA xxxx xxxxxxx

xxxxxxx CASE . 01 xxxx xxxxxxx

CASE STATUS INITIATION CLOSE AP ACTION CASE ACTION

STATUS TYPE DATE DATE REASON CODE EFF DATE CODE EFF DATE

ACOR N UR xx xx xxxx xx xx xxxx \-- IC xx xx xxxx \-- xx xx xxxx

CLOSURE DATE: \_\_\_ \_\_\_ \_\_\_\_\_ SUSPEND TEMP

UNIT CSS WRKR BILLING DISTRIBUTION DISBURSEMENT IRS OFFSET IRS OFFSET
CSRA

XXX XX XXXX A B Y

WORKER ID: WORKER NAME:

ADDRESS INSUFF ADJ REFERRAL: APPROVED: DAYS

MATCH FUNDS APPOINTMENT INTERVIEWER CL/AP DATE TIME LEFT

-380

WAGE REVIEW FEE SERVICE BILL AP/CL DATE LOCATION

GARN CODE PAID LEVEL CD MARRIAGE: NUMBER

C Y B 01 DIVORCE:

TRANSFER CASE RIGHTS ASSIGNED SEPARATED:

ALT CL:

**\*\* FAMILY VIOLENCE \*\* \_\_\_\_** GOOD CAUSE NEXT

COOPERATION BASIS DETERMINATION ENFORCEMENT CLAIM DATE CSE REVIEW

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: APPD C CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment C**

xx/xx/xx xx:xx CHILD DATA xxxx xxxxxxx

xxxxxxx CHLD . 01 xxxx xxxxxxx

CHILD NAME DHS PROGRAMS

LAST FIRST I MOD SSN V S FIP FS MA GPA IVF

DOE MICHAEL xxx-xx-xxxx M

BENEFITS FROM ABSENT PARENT BIRTH PLACE BIRTH DATE

XX XX XXXX

**\*\* FAMILY VIOLENCE \*\* Y**

RELATIONSHIP PATERNITY MED I CHILD INCLUDED IN SUPPORT ORDER

OF: AP CLIENT STATUS DATE ORDR (Y/N) AMOUNT FREQ ORDER DATE

1 1 PDS XX XX XXXX

ETH 1 CIT Y ED XX STATUS

F I P E L E G I B I L I T Y

DPRV CURRENT STD- CSE REMOVAL

START DATE CODE BENEFIT FIP REASON EFF DATE

XX XX XX XXXX

ADDRESS OF CHILD IF NOT LIVING WITH CLIENT

ADDRESS1 ADDRESS2

CITY STATE ZIP CTRY SRC OF VERIFICATION

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: APPD C CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment D**

xx/xx/xx xx:xx CLIENT DATA xxxx xxxxxxx

xxxxxxx CLNT . 01 xxxx xxxxxxx

CLIENT NAME PRES DHS PROGRAMS

LAST FIRST I MOD SSN V S MS AFDC FS MA GPA IVF PR

DOE JANE xxx-xx-xxxx Y F A A A PTH

MAIDEN NAME REL TO AP ETH CIT ED LANGUAGE OCCUPATION BIRTH DATE

M 2 Y 13 XX XX XXXX

OTHER NAME: ALTERNATE PAYEE ALTERNATE CLIENT

**\*\* FAMILY VIOLENCE \*\* Y** MAILING ADDRESS

STREET P.O. BOX / FLOOR / ROUTE CITY ST ZIP

123 MAIN STREET PROVIDENCE RI XXXXX

COUNTRY CD: ADDR STATUS: V BY: XXXX DT: XX XX XXXX MA NUMBER: XXXXXXX

RESIDENCE ADDRESS IS DIFFERENT THAN MAILING ADDRESS

STREET P.O. BOX / FLOOR / ROUTE CITY ST ZIP

COUNTRY CD: ADDR STATUS: BY: DT: TOWN CD:

WORK TELEPHONE HOME TELEPHONE

AREA NUMBER EXT NOTE AREA NUMBER EXT NOTE

( ) ( )

EMPLOYER ID: EMP NAME:

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: APPD C CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment E**

xx/xx/xx xx:xx COMMON CASE DATA xxxx xxxxxxx

xxxxxxx COMM . 01 xxxx xxxxxxx

CODE MM DD YYYY RHODE ISLAND OUT OF STATE CASE STATUS

AP ACTION IC XX XX XXXX DOCKET DOCKET STATUS TYPE EFF DATE

CASE ACTION XXXXXXX ACOR N UR xx xx xxxx

ABSENT PARENT EMPLOYER

NAME: DOE, JOHN ACME WIDGET CO

STREET: EMP ID: XXXXXXXXXX

PO BOX: ROUTE: APT:

CITY, ST, ZIP: PROVIDENCE RI XXXXX CTY: ADDR STAT: V

PHONE: TOWN: INTERSTATE WG CR:

LOC SRC: DOC VER SRC: DOC BY: DOC DT: XX XX XXXX

CURRENT SUPPORT ORDER LAST PAID ARREARAGES SERVLVL: B

XX XX XXXX 200.00 A XX XX XXXX A: -9000.00 N: 13308.81 O:

CLIENT

NAME: DOE, JANE

STREET: 123 MAIN STREET **\*\* FAMILY VIOLENCE \*\* Y**

PO BOX:

CITY, ST, ZIP: PROVIDENCE RI XXXXX CTY:

PHONE:

CHECK CAT: LAST CHECK: AMT:

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: COMM D CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment F**

xx/xx/xx xx:xx ABSENT PARENT CASES xxxx xxxxxxx

xxxxxxx ACAS . 01 xxxx xxxxxxx

ABSENT PARENT NAME HOME ADDRESS

LAST FIRST I MOD STREET MAX ACI

DOE JOHN P.O. BOX RTE APT

CITY PROVIDENCE ST RI ZIP xxxxx CTY

TELEPHONES MAIL ADDRESS

AREA NUMBER EXT NOTE STREET

HOME: P.O. BOX

WORK: CITY ST ZIP CTY

CLIENT CLIENT NAME **FAMILY** SSN CLS RSN

X OF X DOE JANE **VIOLENCE: Y** xxx xx xxxx

ORDER DOCKET SUPP ORDER FREQ A ARRS N ARRS OTHER LAST PMT

XX xxxxxxx 200.00 A -9000.00 13308.81 xx xx xxxx

OFFSETS: FIP: NON-FIP: OTHER:

CHILD NAME CHILD NAME

DOE MICHAEL

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: ACAS D CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment G**

xx/xx/xx xx:xx CLIENT CASES xxxx xxxxxxx

xxxxxxx CCAS . 01 xxxx xxxxxxx

CLIENT NAME CLIENT MAIL ADDRESS

LAST FIRST I MOD STREET 123 MAIN STREET

DOE JANE P.O. BOX

CITY PROVIDENCE ST RI ZIP xxxxx CTY

ALTERNATE CLIENT: CLIENT HOME ADDRESS

TEL: AREA NUMBER EXT NOTE STREET

HOME: P.O. BOX

WORK: CITY ST ZIP CTY

AP ABSENT PARENT NAME **FAMILY** SSN CLS RSN

X OF X DOE JOHN **VIOLENCE: Y** xxx xx xxxx

ORDER DOCKET SUPP ORDER FREQ A ARRS N ARRS OTHER LAST PMT

XX xxxxxxx 200.00 A -9000.00 13308.81 xx xx xxxx

OFFSETS: FIP: NON-FIP: OTHER:

CHILD NAME CHILD NAME

DOE MICHAEL

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: ACAS D CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment H**

xx/xx/xx xx:xx CASE TRACKING xxxx xxxxxxx

xxxxxxx CCAS . 01 CASE HISTORY xxxx xxxxxxx

STARTING DATE XX XX XXXX

SELECTION CONTACTS & COMMENTS

XX/XX/XX \[CASEWORKER NAME\] \[ID\] ENTERED COMMENT

**FAMILY VIOLENCE INDICATOR CHANGED FROM 'N' TO 'Y'**

FROM CASE DATA PANEL

RL: XX XX XX ABSP: XXX XX XXXX DOE JOHN CMD:

FNX: ACAS D CLIENT: XXX XX XXXX DOE JANE PNL:

**Attachment I**

**WARNING: CASE IS FLAGGED FOR FAMILY VIOLENCE**

XX/XX/XX XX:XX SELECT FUNCTION XXXX XXXXXX

XXXXXXX XXXX IV-D XXXX XXXXXXX

FUNCTION MODE FUNCTION MODE

ACAS ABSENT PARENT CASES D ADDS ACCESS DATA DICTIONARY C D

AFIX CASE SEPARATION C APPD APPLICATION E C D

BGBH CASE INTERFACE C CALC CALCULATE ADJUSTMENT C D

CCAS CLIENT PARENT CASES D CNET CSENET D

CODE CODE TABLES C D COMM COMMON CASE D

CONT CONTACT C D CORT COURT FUNCTIONS C D

CSRS CASE RESOLUTION C CS10 OLD IV-D DATA D

DAIL DAILY REPORTS C DELE DELETE CASE C

DIST MONTHLY DISTRIBUTION D FORM FORMS C

FIXX SPECIAL CORRECTIONS C FSUM FINANCIAL SUMMARY D

GUID GUIDELINE CALCULATION C D INTR INTERFACES C D

IV-A IV-A DATA D IV-F PATHWAYS (AFDC) D

FUNCTION MODE CASE ID MONTH

XXXX X XXX XX XXXX X XX XX

###### Attachment J

L E G A L U N I T F O R M

ABSENT PARENT NAME DOCKET CNTY CLDR CLDR MA

CASE ID LAST FIRST I NUMBER CD TYPE DATE NBR

xxxxxxxxxx DOE JOHN xxxxxxx

ALL MEMBERS OF THE CASE

NL LAST FIRST I REASON AFIC FS MA GPA SSN

CL DOE JANE A A xxx xx xxxx

AP DOE JOHN xxx xx xxxx

CH DOE MICHAEL A A xxx xx xxxx

CLIENT DATA **\*\* FAMILY VIOLENCE \*\***

DOE JANE

123 MAIN STREET PROVIDENCE RI XXXXX

PHONE NUMBER START DATE STD EEN ETH EIUCA

XX XX XXXX X XX

CHILD DATA

PAT SUPP REL AFDC CURR

STATUS ORDER AMT FREQ TO: AP CLNT START EEN SEX BIRTH DATE

DOE MICHAEL 0.00 X X XX XX XXXX M XX XX XXXX

ALL CHILDREN IN GRANT

LAST FIRST I

ABSENT PARENT DATA PHONE

DOE JOHN

111 NORTH PROVIDENCE RI XXXXX

VERIFICATION MARITAL WAGE

SRC BY DATE STATUS DATE EMPLOYER

CL xxxxxxx xx xx xxxx

*People involved in child support cases or orders in Rhode Island may
inform the child support agency or the court of their concerns about
safety. The State has revised the data collection form \-- the "Child
Support Information and Payment Form" \-- to permit the court to gather
this information. That form appears on the next page, with the relevant
check-off box highlighted. Appropriate sections of the form's
instructions appear immediately after the form. Also included is the
administrative order that mandates completion of the form.*

### STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

**RHODE ISLAND FAMILY COURT**

**ONE DORRANCE PLAZA**

**PROVIDENCE, RI 02903**

**[CHILD SUPPORT INFORMATION AND PAYMENT FORM]{.underline}**

**SECTION A (COMPLETE THIS SECTION [IN FULL]{.underline} FOR
[ALL]{.underline} NEW OR MODIFIED CHILD SUPPORT ORDERS)**

+-----------------------------------------------------------------------+
| FILE NUMBER COUNTY                                                    |
|                                                                       |
| OBLIGATOR NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_ OBLIGEE NAME:                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_        |
| \_\_\_\_                                                              |
|                                                                       |
| FIRST MI LAST MOD FIRST MI LAST MOD                                   |
|                                                                       |
| \[ \] PLAINTIFF \[ \] DEFENDANT \[ \] PLAINTIFF \[ \] DEFENDANT       |
|                                                                       |
| ADDRESS: ADDRESS:                                                     |
|                                                                       |
| CITY/STATE: ZIP: CITY/STATE: ZIP:                                     |
|                                                                       |
| DOB: SSN: SEX: DOB: SSN: SEX:                                         |
|                                                                       |
| DRIVER'S LICENSE #: \[ \] **PROTECT ADDRESS DUE TO DOMESTIC VIOLENCE  |
| (SEE INSTRUCTIONS)**                                                  |
|                                                                       |
| **IF CHECKED, WHOSE ADDRESS? \[ \] OBLIGEE/CHILD(REN) \[ \] OBLIGOR** |
|                                                                       |
| OBLIGATOR'S EMPLOYER NAME: ADDRESS:                                   |
|                                                                       |
| CITY/STATE: ZIP: PHONE:                                               |
|                                                                       |
| [DEFENDENTS]{.underline} (ATTACH ADDITIONAL SHEET IF MORE THAN FOUR   |
| CHILDREN)                                                             |
|                                                                       |
| NAME: SEX: \_\_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SSN:  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| FIRST MI LAST                                                         |
|                                                                       |
| NAME: SEX: \_\_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SSN:  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| FIRST MI LAST                                                         |
|                                                                       |
| NAME: SEX: \_\_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SSN:  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| FIRST MI LAST                                                         |
|                                                                       |
| NAME: SEX: \_\_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SSN:  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| FIRST MI LAST                                                         |
+-----------------------------------------------------------------------+
| **SECTION B (COMPLETE THIS SECTION [ONLY]{.underline} WHEN NEW OR     |
| MODIFIED CHILD SUPPORT PAYMENTS ARE TO BE PAID THROUGH FAMILY         |
| COURT)**                                                              |
+-----------------------------------------------------------------------+
| [ORDER INFORMATION]{.underline}                                       |
|                                                                       |
| \[ \] NEW/MODIFIED ORDER \[ \] PAYMENTS ARE HEREBY SUSPENDED          |
| EFFECTIVE DATE:                                                       |
|                                                                       |
| MERGED WITH RECIPROCAL? \[ \] YES \[ \] NO IF YES, RECIPROCAL NO.:    |
|                                                                       |
| WAGE ASSIGNMENT ORDERED? \[ \] YES \[ \] NO \[ \] WAGE ASSIGNMENT     |
| FORM ATTACHED                                                         |
|                                                                       |
| CHILD SUPPORT AMOUNT: \$ \_\_\_\_\_\_\_\_ FREQUENCY: \_\_\_\_\_\_\_   |
| ARREARAGE ORDER AMOUNT:\$ \_\_\_\_\_\_\_\_ FREQUENCY: \_\_\_\_\_\_    |
|                                                                       |
| SPOUSAL SUPPORT AMOUNT:\$ \_\_\_\_\_\_\_\_\_\_ FREQUENCY:             |
| \_\_\_\_\_\_\_\_\_\_ MEDICAL REIMBURSEMENT AMOUNT: \$                 |
| \_\_\_\_\_\_\_\_\_\_\_\_\_                                            |
|                                                                       |
| DATE FIRST PAYMENT DUE: \_\_\_\_\_\_\_\_\_\_ HEARING DATE:            |
| \_\_\_\_\_\_\_\_\_\_ JUDGE/MAGISTRATE:                                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| FIXED AMOUNT OF ARREARAGE: \[ \] STATE: \$\_\_\_\_\_\_\_\_\_\_ \[ \]  |
| CLIENT: \$ \_\_\_\_\_\_\_\_\_\_ AS OF (DATE):                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_                                            |
|                                                                       |
| INTEREST ON ARREARS? \[ \] YES \[ \] NO \[ \] ORDER ATTACHED          |
|                                                                       |
| MEDICAL SUPPORT ORDERED? \[ \] YES \[ \] NO IF YES, \[ \] MAINTAIN    |
| INSURANCE \[ \] OBTAIN INSURANCE, WHEN AVAILABLE                      |
|                                                                       |
| OBLIGOR ATTORNEY NAME:                                                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |
| PHONE NO.: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ RI BAR NO.:                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                        |
|                                                                       |
| OBLIGEE ATTORNEY NAME:                                                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |
| PHONE NO.: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ RI BAR NO.:                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                        |
+-----------------------------------------------------------------------+
| **SECTION C (PAYMENTS RECEIVED BY FAMILY COURT CANNOT BE DISBURSED TO |
| THE OBLIGEE UNLESS THIS SECTION OF THE FORM IS COMPLETED)**           |
+-----------------------------------------------------------------------+
| [APPLICATION FOR COLLECTION SERVICES]{.underline}                     |
|                                                                       |
| UPON MY SIGNATURE TO THIS FORM, I AUTHORIZE THE RHODE ISLAND FAMILY   |
| COURT, THROUGH ITS COOPERATIVE AGREEMENT WITH THE DIVISION OF         |
| TAXATION \-- CHILD SUPPORT ENFORCEMENT, TO COLLECT MY CHILD SUPPORT   |
| AND FORWARD THE SAME TO ME. I DESIRE THE FOLLOWING SERVICES:          |
|                                                                       |
| \[ \] BOOKKEEPING SERVICES ONLY (SEE INSTRUCTIONS) \[ \] FULL         |
| SERVICES (\$20 FEE ATTACHED \-- SEE INSTRUCTIONS)                     |
|                                                                       |
| DATE: OBLIGEE SIGNATURE:                                              |
+-----------------------------------------------------------------------+

CSS-1 (REV. 11/98)

#### INSTRUCTIONS TO COMPLETE A CHILD SUPPORT INFORMATION AND

**[PAYMENT FORM (CSS-I)]{.underline}**

Both parties are responsible to provide complete and accurate
information to complete the Child Support Information and Payment Form
(CSS-1). The obligee or the obligee's attorney [must]{.underline}
complete and file the form immediately after the hearing and before
leaving court.

**[SECTION A]{.underline} \--THIS SECTION [MUST]{.underline} BE
COMPLETED IN FULL FOR [ALL]{.underline} CASES IN WHICH THERE IS A NEW OR
MODIFIED CHILD SUPPORT ORDER, REGARDLESS OF WHETHER OR NOT THE CHILD
SUPPORT AGENCY IS INVOLVED IN THE ACTION. [PLEASE PRINT OR TYPE ALL
INFORMATION]{.underline}.**

**1. DEFINITIONS:**

Obligor \-- The individual who has responsibility to pay the child
support order.

Obligee \-- The individual to whom the child support order is owed.

Domestic Violence \-- Pursuant to Section 40-5.1-46 of the Rhode Island
General Laws, a history of

> domestic violence means that an individual has been subjected to:

(i) Physical acts that resulted in, or threatened to result in physical
    injury to the

> individual;
>
> \(ii\) Sexual abuse;
>
> \(iii\) Sexual activity involving a dependent child;

(iv) Being forced as the caretaker relative of a dependent child to
     engage in

> nonconsensual sexual acts or activities;
>
> \(v\) Threats of, or attempts at, physical or sexual abuse;
>
> \(vi\) Mental abuse; or
>
> \(vii\) Neglect or deprivation of medical care.

**2. DATA ELEMENTS:**

\* \* \*

[PROTECT ADDRESS DUE]{.underline}

[TO DOMESTIC VIOLENCE]{.underline} \-- Certain information contained on
this form, including the domestic violence indicator, will be provided
to the Federal Case Registry (FCR), for possible further dissemination
pursuant to federal law. **Check this box if you believe there is a
history of domestic violence as defined above and indicate whether you
are referring to the obligee/child(ren) and/or the obligor.** This will
prevent the FCR from releasing the address information to anyone without
a court order. **[IN ORDER TO PROTECT THE CONFIDENTIALITY OF THE ADDRESS
OF THE OBLIGOR AND OR OBLIGEE/CHILD(REN) CONTAINED IN THE COURT FILE,
YOU MUST FILE A MOTION FOR NONDISCLOSURE OR A MOTION TO SEAL THE FILE AT
FAMILY COURT AND SEEK COURT APPROVAL. OTHERWISE, THE FILE SHALL REMAIN
OPEN AS A PUBLIC RECORD AND, IF THE ADDRESS IS CONTAINED IN THE COURT
FILE, IT MAY BE AVAILABLE FOR PUBLIC INSPECTION. IF YOU LEAVE THE
DOMESTIC VIOLENCE BOX UNCHECKED IT WILL BE ASSUMED THAT YOU DO NOT WISH
TO PROTECT INFORMATION ABOUT THE WHEREABOUTS OF THE OBLIGOR OR
OBLIGEE.]{.underline}**

\* \* \*

**RHODE ISLAND FAMILY COURT**

**ADMINISTRATIVE ORDER 98-8**

**RE: [STATE CASE REGISTRY FOR CHILD SUPPORT ORDERS]{.underline}**

In accordance with P.L. 1997, ch. 170, Section 1 amending Rhode Island
General Laws Section 15-5-16.2(h), all child support orders (including
temporary orders) established or modified in Rhode Island on or after
[October 1, 1998]{.underline}, shall be recorded with the Rhode Island
Family Court/Department of Administration, Division of Taxation \--
Child Support Enforcement System which maintains the official State Case
Registry of child support orders issued by the Rhode Island Family
Court. The child support order shall be recorded whether or not services
are being provided under the IV-D State plan and whether or not payments
are being made through the Family Court. The information provided to the
State Case Registry will be furnished to the Federal Case Registry of
child support orders.

To effectuate the aforementioned law, each party to a child support or
paternity proceeding (Domestic Relations and Reciprocal cases) shall
provide complete and accurate information to the obligee's attorney or
obligee, if pro se, in order to complete a Child Support Information and
Payment Form (CSS-1, as revised; see attached). The obligee's attorney
or obligee, if pro se, shall complete and file with the Family Court the
CSS-1 form immediately after the court hearing and before leaving the
court. Instructions to execute the CSS-1 form are attached hereto and
shall be followed.

Therefore, each party is required within 10 days to file an amended
CSS-1 form whenever any of the information contained in the original
form has changed in any way.

Failure to file the CSS-1 form may result in sanctions being assessed.

Date [10/1/98]{.underline} [/s/]{.underline}

Jeremiah S. Jeremiah, Jr.

Chief Judge

*Rhode Island's child support staff and its court have begun working
together to develop the State-specific components of the override
process. The pages that follow include documents developed in connection
with this process. Work to finalize the process continues.*

![](media/image1.png)STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

Department of Administration

DIVISION OF TAXATION \-- CHILD SUPPORT ENFORCEMENT

OFFICE OF LEGAL COUNSEL

77 Dorrance Street, 3rd Floor

Providence, RI 02903 February 4, 1999

Magistrate George DiMuro

Court Administrator

Rhode Island Family Court

One Dorrance Plaza

Providence, Rhode Island 02903

**Re: [Domestic Violence Indicator Override Procedure]{.underline}**

Dear Magistrate DiMuro:

> Pursuant to our meeting of January 14, 1999 I have drafted the
> following forms for your review.

1\. Request for information

2\. Notice to Non-requesting party

3\. Denial of Requested Information

4\. Release of Requested Information

5\. Motion for Release of Information

6\. Order for Release of Information

7\. Cover letter to Federal Parent Locator Service

> The procedure will be that outlined in the federal action transmittal.
>
> \<\> Requestor requests the information from the State CSE on the form
> provided.
>
> \<\> CSE will notify the non-requesting party.
>
> \<\> The information will be provided if there is no (family) domestic
> violence indicator and the other requirements are met.
>
> \<\> If there is an indicator as determined by OCSE, the requestor
> will be notified on the form provided and a sample motion will be
> provided.
>
> \<\> A hearing will be assigned by the Clerk's Office.
>
> \<\> During the hearing, the court must determine whether the
> disclosure to any other person of that information could be harmful to
> the parent or the child.
>
> \<\> If the court determines the information may be released, the
> order (form attached) is sent to the CSE.
>
> \<\> CSE then sends the cover letter to the OCSE with the order by
> federal express.
>
> \<\> If the information is released to CSE, the information will be
> delivered to the court in a sealed envelope. If the request is
> disapproved or incomplete, this will also be conveyed to the court.

Perhaps we should schedule another meeting to discuss these forms.

Very truly yours,

SHARON A. SANTILLI

CHIEF LEGAL COUNSEL

CHILD SUPPORT ENFORCEMENT

SAS:1p

Enclosures

# STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

**DEPARTMENT OF ADMINISTRATION / DIVISION OF TAXATION**

**CHILD SUPPORT ENFORCEMENT**

**77 DORRANCE STREET**

**PROVIDENCE, RHODE ISLAND 02903**

**(401) 222-2847**

**REQUEST FOR INFORMATION**

I swear that the statements contained on this form are true.

I am an authorized person to receive information under Federal law
because I am:

\[ \] A resident parent requesting information about the other parent of
our child(ren).

\.... The child(ren)'s usual place of residence is with me.

\.... The child(ren) are not receiving assistance in the form of FIP

or TANF payments from the state.

\.... I am not under a court order to pay current, on-going support

for the child(ren).

\[ \] The guardian of the child(ren) as shown in the attached written
documentation.

\[ \] The agent of the child(ren) as shown in the attached written
documentation.

\[ \] The attorney of the child(ren) as shown in the attached written
documentation.

Child(ren)'s names:

I am requesting information about:

Name:

Information Requested (please be specific):

Provide the following information **about the subject of the request,**
if known: (45 CFE \[sic\] 303.70)

Social Security Number:

Has the subject served in branch of the armed forces?:

If yes, Branch:

Is the subject receiving federal benefits?

I am requesting this information **solely** for the purpose of:

\[ \] Establishing, enforcing or modifying an order for child support.

\[ \] Establishing, enforcing or modifying an order for visitation.

\[ \] Establishing, enforcing or modifying an order for custody.

\[ \] Establishing paternity.

I certify under penalty of perjury and pursuant to the laws of the State
of Rhode Island that the preceding is true and correct.

SIGNATURE OF REQUESTER DATE OF SIGNATURE

**Request for Information, page 3**

The person about whom you are requesting information will be notified of
your request. A copy of page 1 and 2 will be sent with the notice. The
law allows a 30 day time period for a response. We will notify you after
30 days whether your request for information is granted or denied.

Fill out the following about **yourself**. This information is for
identification and communication with you. It will not be used for any
other purposes. This page **will not** be sent with the notice to the
person about whom you are requesting information.

**Name**

**Street Address**

**City State ZIP Code**

**Telephone Number**

**(Home)**

**(Business)**

**Social Security Number or CSE No.**

Return this completed form to:

> Division of Taxation
>
> Child Support Enforcement
>
> 77 Dorrance Street
>
> Providence, RI 02903

# STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

**DEPARTMENT OF ADMINISTRATION / DIVISION OF TAXATION**

**CHILD SUPPORT ENFORCEMENT**

**77 DORRANCE STREET**

**PROVIDENCE, RHODE ISLAND 02903**

**(401) 222 - 2847**

**NOTICE TO NON-REQUESTING PARTY**

**OF REQUEST FOR DISCLOSURE OF INFORMATION**

Date:

NAME

ADDRESS 1

ADDRESS 2

CITYSTATEZIP

The Child Support Enforcement agency has received a request for
information concerning:

The reason stated for this is for the purpose of:

This information may include the following:

If you have questions concerning this notice, please call Child Support
Enforcement at 1-800-638-5437 (1-800-RI-CHILD) or (401) 222-2847.

Please send any relevant documentation **within 20 days of the date of
this notice**.

> Division of Taxation
>
> Child Support Enforcement
>
> 77 Dorrance Street
>
> Providence, RI 02903

# STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

# DEPARTMENT OF ADMINISTRATION / DIVISION OF TAXATION

**CHILD SUPPORT ENFORCEMENT**

**77 DORRANCE STREET**

**PROVIDENCE, RHODE ISLAND 02903**

**(401) 222-2847**

**DENIAL OF REQUESTED INFORMATION**

Date:

NAME

ADDRESS 1

ADDRESS 2

CITYSTATEZIP

You requested information about \[REQ NAME\], the information cannot be
released to you because \[OTHER REASON\] . This decision is based on
Section 453(b)(2) of the Social Security Act.

If you have any questions, please contact Child Support Enforcement at
1-800-638-5437 (1-800-RI-CHILD) or (401) 222-2847.

If you disagree with this denial of your request for information, you
may file a motion with the Rhode Island Family Court using the form
motion enclosed for your convenience.

> Division of Taxation
>
> Child Support Enforcement
>
> 77 Dorrance Street
>
> Providence, RI 02903

# STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

**DEPARTMENT OF ADMINISTRATION / DIVISION OF TAXATION**

**CHILD SUPPORT ENFORCEMENT**

**77 DORRANCE STREET**

**PROVIDENCE, RHODE ISLAND 02903**

**(401) 222-2847**

**RELEASE OF REQUESTED INFORMATION**

Date:

NAME

ADDRESS 1

ADDRESS 2

CITYSTATEZIP

You requested the following information as an authorized person pursuant
to Section 463(a)(2) of the Social Security Act. You stated that the
information is requested solely for the purpose of:

Requested Information:

INFO NAME

INFO SSN

If you have any questions, please contact Child Support Enforcement at
1-800-638-5437 (1-800-RI-CHILD) or (401) 222-28547.

Division of Taxation

CHILD Support Enforcement

77 Dorrance Street

Providence, RI 02903

STATE OR RHODE ISLAND FAMILY COURT

SC.

FAMILY COURT NO.

vs.

**[MOTION FOR RELEASE OF INFORMATION]{.underline}**

Now comes the in the above-captioned mat\[t\]er and moves this honorable
court to release information about the contained on the family court /
child support enforcement system pursuant to Section 453(b)(2)(B) of the
Social Security Act. In support of said motion the movant alleges as
follows:

1\. I am an authorized person to receive information as defined by
sections 453(c) and 463(a)(2) of the Act because I am:

> \_\_\_\_\_ A resident parent requesting information about the other
> parent of our child(ren).
>
> \<\> The child(ren)\['s\] usual place of residence is with me.
>
> \<\> The child(ren) are not receiving assistance in the form of FIP
> payments from the State.
>
> \<\> I am not under a court order to pay.
>
> \_\_\_\_\_ The guardian of the child(ren) as shown in the attached
> documentation.
>
> \_\_\_\_\_ The agent of the child(ren).
>
> \_\_\_\_\_ The attorney of the child(ren).

2\. The information is being sought for an authorized purpose.

3\. The release of the information requested will not be harmful to the
parent or child(ren).

4\. That \[sic\] this court has proper jurisdiction in this case
pursuant to Section 453(c)(2).

WHEREFORE, the respectfully requests an order be issued to release the
information sought and for further relief as the court deems fair and
just under the circumstances.

REQUESTOR'S NAME

ADDRESS

SOCIAL SECURITY NO.

To: Division of Taxation \-- Child Support Enforcement

77 Dorrance Street

Providence, Rhode Island

[NOTICE]{.underline}

Please take notice that the above-captioned matter will be called for
hearing in courtroom 5c at the J. Joseph Garrahy Judicial Complex, One
Dorrance Plaza, Providence, RI on .

STATE OR RHODE ISLAND FAMILY COURT

SC.

FAMILY COURT NO.

vs.

**[ORDERED, ADJUDGED AND DECREED]{.underline}**

The motion for release of information is:

> \_\_\_\_\_ Denied in that the release of the information could be
> harmful to the parent/child(ren).
>
> \_\_\_\_\_ Granted in that the release of the information would not be
> harmful to the parent/child. The following information shall be
> released to the court directly for the purpose of :
>
> \_\_\_\_\_ Address of non-requestor
>
> \_\_\_\_\_ Phone number of non-requestor
>
> \_\_\_\_\_ Child's date of birth
>
> \_\_\_\_\_ Child's social security number

ORDERED: ENTERED:

J. Clerk

Date Date

**STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS**

**DEPARTMENT OF ADMINISTRATION / DIVISION OF TAXATION**

**CHILD SUPPORT ENFORCEMENT**

### 77 DORRANCE STREET

**PROVIDENCE, RHODE ISLAND 02903**

**(401) 222-2847**

FCR FAMILY VIOLENCE INDICATOR

OVERRIDE PROCESS

\* \* \*

\[DATE\]

Office of Child Support Enforcement

Attn: OCSE Designated Representative

Federal Parent Locator

370 L'Enfant Promenade

4th Floor

Washington, DC 20447

Dear \[NAME\]:

This office has submitted a locate request to the Federal Parent Locator
Service (FPLS) for the subject(s) listed below. Access to the requested
information was prohibited because of a disclosure prohibited (DP) code.

Attached is a court order or request from \[COURT NAME\] requiring this
office to commence the FV indicator override process. Accordingly,
accept this letter as a formal request for override.

To assist OCSE in processing this override request, this office provides
the following information:

Name of Requester:

SSN of Requester (if an individual):

Relationship of Requester to Subject:

Basis for State Finding that

1\) Requester is an authorized person; and

2\) Request is made for a permissible purpose:

Name(s) of Subject(s):

SSN(s) of Subject(s):

Member ID(s) (if applicable):

Specify Requested Locate Sources:

All available locate sources

DOD and OPM

FBI employment files

IRS (non-1099)

SSA

DVA

NDNH

FCR

Specify Locate Request Type

Adoption or foster care purposes

IV-D Purposes

Custody and visitation establishment or enforcement purposes

Parental Kidnapping

Name of SPLS Representative

Street Address of SPLS Representative

Direct Dial Phone Number of SPLS Representative

Sincerely,

\[NAME\]

\[TITLE\]