Use State Letterhead

Date:

Office of Child Support Enforcement

Department of Health and Human Services

Federal Collections and Enforcement

370 L\'Enfant Promenade, SW, 4^th^ Floor

Washington, D.C. 20447

From:
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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 child and/or
spousal 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 child
> 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 (for a child and the
    parent with whom the child is living) 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.

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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 parent attesting to the amount
    of support owed and has, in non-assistance cases, the custodial
    parent\'s current address.

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3.  The Pre-Offset Notice that we will issue to the obligor 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.

I certify that every request for passport denial meets the following
requirements:

1.  The amount of the child support arrearage owed by the individual
    exceeds \$2,500.

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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 parent attesting to
    the amount of support owed.

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3.  The Pre-Offset Notice that we will issue to the obligor 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 meets the following requirements:

1.  There is a delinquent amount of child and/or spousal support owed.

2.  The amount of the delinquency is greater than zero.

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.

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Information for Pre-Offset and/or Financial Management Services (FMS)
Offset Notice:

We request that OCSE mail Pre-Offset Notices to noncustodial parents.
\_\_\_\_\_Yes\_\_\_\_\_No

Which address type should be used on your State's OCSE-issued Pre-Offset
Notice and/or Treasury's FMS Offset Notice?

Choose one of the following for each category:

[OCSE-Issued Pre-Offset Notice:]{.underline}

> \_\_\_\_ 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
>
> \_\_\_\_ N/A; our State issues its own Pre-Offset Notice

[FMS Offset Notice:]{.underline}

> \_\_\_\_ Use State Contact Address
>
> \_\_\_\_ Use Local Contact Address

[State IV-D Address:]{.underline}

> All States must provide a State IV-D address, whether or not local
> addresses are used.
>
> (Please note that the State IV-D address indicated below may be used
> as the contact information included in one or both of the notices
> sent).
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Telephone: (\_\_\_\_\_\_) \_\_\_\_\_\_\_ -
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Telephone 2 (Optional): (\_\_\_\_\_\_) \_\_\_\_\_\_\_ -
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How long does your State want OCSE to hold new cases from the Pre-Offset
Notice date before forwarding to FMS for offset certification?

\_\_\_ 30 days

> \_\_\_ 45 days
>
> \_\_\_ 60 days
>
> \_\_\_ 90 days

Signature of IV-D Director or Designee
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Agency Contact
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Agency Contact\'s Phone Number
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Agency Contact's E-Mail Address
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