N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. IV, subch. A, Uniform Interstate Family Support Act Forms, UIFSA-9 - Registration statement

F.C.A. Art. 5-B UIFSA-9

REGISTRATION STATEMENT

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Responding IV-D Case No. ____________ Initiating IV-D Case No. ________

Responding Docket No. ____________ Initiating Docket No. ________

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I. Case Summary (Background of this Matter: Court / Administrative Actions)

Date of Support Order State and County Issuing Order Tribunal Case No.

Support Amount/Frequency Date of Last Payment Amount of Arrears Period of Computation

$ $

___

Date thru

___

Date

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II. Mother Information [ ] Obligor [ ]Obligee

Full Name and Aliases Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip)

(First, Middle, Last)

SSN:

____________

III. Father Information [ ] Obligor [ ]Obligee

Full Name and Aliases Address (Street, City, State, Zip) Employer (Name, Street, City, State, Zip)

(First, Middle, Last)

SSN:

____________

IV. Caretaker (If Not a Parent) Relationship to Child(ren) ____________

Full Name and Aliases Address (Street, City, State, Zip)

(First, Middle, Last)

SSN:

____________

V. Additional Case Information

This order is registered in the following states:

Description and location of any property not exempt from execution:

Other:

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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

[ ] Party seeking Registration [ ] Records Custodian

_______

Sworn to and Signed

______________

Notary Public, Court/Agency Official and Title

______

Commission Expires

Before Me This

Date, County/State

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Registration Statement OMB No. 0970 - 0085 Page 1 of 1

OMB-No. 0970 - 0085

INSTRUCTIONS FOR REGISTRATION STATEMENT

PURPOSE OF THE FORM: The Registration Statement is completed by the initiating jurisdiction to request registration of an existing order for enforcement and/or modification. The purpose of the form is to refer specific order information to the responding State. This form can be used in IV-D and non-IV-D interstate cases. It should be included with the other appropriate forms and directed to the responding State's central registry. It is important to remember that a separate Registration Statement is needed for each order that the initiating State is requesting be registered by the responding State.

HEADING/CAPTION:

The initiating jurisdiction add its IV-D case and docket numbers to the heading, at the space available. The responding jurisdiction will add its IV-D case and docket numbers to the heading after receiving the form from the initiating jurisdiction.

SECTION I, CASE SUMMARY:

Provide complete information for all court/administrative actions regarding support for dependents. Use a separate Registration Statement form for each court/administrative order you are requesting be registered. For "Period of Computation", enter the month, day, and year for both the beginning and ending dates. The information in this section will be used to aid in verifying calculated arrearages and to assist in determining/verifying which order is controlling and which State has continuing exclusive jurisdiction.

Attach the required number of copies of all pertinent order that relate to support. If you are sending this case to a State that uses UIFSA, you will generally need to attach two copies, one of which is certified, of any support order. If your are sending this case to a State that uses a version of URESA, you will generally need to attach three certified copies of any support order. Note, however, that some responding States may be able to take certain administrative enforcement actions (e.g., interstate wage withholding) without having a certified copy of the order, although a regular copy is necessary.

SECTION II, MOTHER INFORMATION:

This section provides basic information about the child(ren)'s mother. Check the appropriate box to indicate if the mother is the obligor or obligee. Provide the mother's full name (first, middle, last) as well as aliases or maiden name, and all other information.

SECTION III, FATHER INFORMATION:

This section provides basic information about the child(ren)'s father. Check the appropriate box to indicate if the father is the obligor or obligee. Provide the father's full name (first, middle, last) as well as aliases, and all other information. Provide the name and full address for the father's employer.

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Instructions for Registration Statement--Page 1

SECTION IV, CARETAKER (IF NOT A PARENT):

Complete this section only if the child(ren)'s caretaker is not the child(ren)' s parent. In the space labelled "Relationship to Child(ren)", indicate the relationship of the caretaker to the child(ren). Provide the caretaker's full name (first, middle, last) as well as aliases or maiden name, and all other information.

SECTION V, ADDITIONAL CASE INFORMATION:

In this section, provide additional information which may be useful to the responding jurisdiction in working the case, such as a complete listing of all States where the child support order has previously been registered and a description, including the location, of all known property or assets not exempt from execution. In addition to the requested information, use this portion of the form to provide other information which may assist the responding jurisdiction in its efforts to register the order.

SECTION VI, VERIFICATION / CERTIFICATION:

The Registration Statement may be signed by either the party seeking registration or an authorized IV-D representative/records custodian. Check the appropriate box to indicate who has signed this form.

The verification signature requires a notary.

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The Paperwork Reduction Act of 1995

This information collection is conducted in accordance with 45 CFR 303.7 of the child support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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Instructions for Registration Statement--Page 2

Notes

N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. IV, subch. A, Uniform Interstate Family Support Act Forms, UIFSA-9