Child Support Enforcement Transmittal 1 - Initial Request With Registration Statement {FSA-200-1}

CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 ­ INITIAL REQUEST___________ Petitioner IV-D Non Public Assistance IV-D Non PA Medicaid Full Services Respondent Medical Services Only IV-D Public Assistance IV-E Foster Care (IV-D Case) Non-IV-D File Stamp To: (Agency/Tribunal Name and Address) Responding FIPS Code Responding IV-D Case No. Responding Docket No. From: (Contact Person, Agency, Address, Phone, Fax, Internet ) Initiating FIPS Code State State Initiating IV-D Case No. Initiating Docket No. Send Payments To: (If different from above) Payment FIPS Code State Bank Account Code Routing Initiating Jurisdiction URESA UIFSA State with Continuing Exclusive Jurisdiction (CEJ) I. Action. The responding Jurisdiction Should Provide All Appropriate Services Including: 1. Establishment of Paternity 6. Registration of Foreign Support Order: 2. C. Establishment of Order for: For Modification A. Child Support D. Medical Coverage B. For Modification A. Enforcement Only and Enforcement B. Obligee C. Spousal Support State Agency Support for a Prior Period (Requires Sworn E. Other Costs (Use Sec. VII) Requested by: Obligor Statement of Arrears) 3. Enforcement of Responding Tribunal Order 7. Collection of Arrears American LegalNet, Inc. www.FormsWorkflow.com 4. Modification of Responding Tribunal Order 8. Administrative Review for Federal Tax Offset 5. Change of Payee/Redirection of Payment II. Case Summary (Background of this Matter: Court/Administrative Actions) Date of Support Order State & County Issuing Order Case No. Support Amount/Frequency Computation $ Date of Last Payment Amount of Arrears $ Tribunal Period of thru Presumed Controlling Order Date of Support Order Case No. Support Amount/Frequency Computation $ Determined Controlling Order State & County Issuing Order Tribunal Date of Last Payment Amount of Arrears $ Period of thru Presumed Controlling Order Date of Support Order Case No. Support Amount/Frequency Computation $ Determined Controlling Order State & County Issuing Order Tribunal Date of Last Payment Amount of Arrears $ Period of thru Presumed Controlling Order Determined Controlling Order OMB No. 0970 ­ 0085 Child Support Enforcement Transmittal #1 ­ Initial Request Page 1 of 3 FSA-200-1 (Rev. 9-97) Previous edition may be used. American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ENFORCEMENT TRANSMITTAL #1 ­ INITIAL REQUEST___Initiating IV-D Case No., Page 2______________ III. Mother Information Full Name and Aliases Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Home Phone ( ) Employed Confirmed Date Work Phone ( ) Address Confirmed Date Date/Place of Birth Date Place Social Security No. Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) IV. Father Information Full Name and Aliases Home Phone ( ) Employed Confirmed Date Work Phone ( ) Address Confirmed Date Date/Place of Birth Date Place Social Security No. V. Caretaker Information (If Not a Parent) Relationship to Child(ren) Full Name and Aliases Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Home Phone ( ) Employed Confirmed Date Work Phone ( ) Address Confirmed Date Date/Place of Birth No. Date Place Sex Social Security M/F VI. Dependent Children Information Full Name (First, Middle Last) Security No. State of Date of Birth Sex for last 6 months Social American LegalNet, Inc. www.FormsWorkflow.com VII. Additional Case Information VIII. Attachments (Supporting Documentation) Arrears Statement/Payment History Order(s) Uniform Support Petition (3 copies) Decree General Testimony/Affidavit of Rights Affidavit in Support of Establishing Paternity of Real/Personal Property Acknowledgment of Parentage of Respondent Other Documents Relating to Paternity Attachments Support Divorce Assignment Description Photograph Other ( Date ) Initiating Contact Person (Print or Type) Telephone Number & Extension ( ) Fax Number Child Support Enforcement Transmittal #1 ­ Initial Request Page 2 of 3 FSA-200-1 (Rev. 9-97) Previous edition may be used. OMB No. 0970 ­ 0085 American LegalNet, Inc. www.FormsWorkflow.com REGISTRATION STATEMENT Responding IV-D Case No. Initiating IV-D Case No. Responding Docket No. Initiating Docket No. I. Case Summary (Background of this matter: Court/Administrative Actions) Date of Support Order State and County Issuing Order Date of Last Payment Amount of Arrears $ Date Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) Tribunal Case No. Support Amount/Frequency $ II. Mother Information Full Name and Aliases Period of Computati thru Date SSN: III. Father Information Full Name and Aliases Obligor Obligee Address (Street, City, State, Zip) Employer/Address (Name, Street, City, Zip) SSN: IV. Caretaker Information (If Not a Parent) Full Name and Aliases Address (Street, City, State, Zip) Relationship to Child(ren) SSN: V. Additional Case Information This order is registered in the following states: Description and location of any property not exempt from execution: Other: American LegalNet, Inc. www.FormsWorkflow.com VI. Verification/Certification Under penalties of perjury, all information and facts concerning the arrearage accrued under this order are true to the best of my knowledge and belief. Date Sworn t o and Signed Before Me This Date, County/State FSA -207 Registration Statement (Rev. 1-99) Party seeking Registration Records Custodian Commission Expi Notary Public, Court/Agency Official and Title OMB No. 0970-0085 American LegalNet, Inc. www.FormsWorkflow.com