Administrative Subpoena

TO:
(Name, address)

Regarding:
(name, DOB, SSN)

Case Caption:

FROM:
(CSE Agency, address, phone, e-mail address, fax number)

IV-D Case Number:

 

Under Federal law (42 U.S.C. 666(c)(1)(B)) and similar statutes in this and all other States, you are required to provide financial or other information needed to establish, modify, or enforce a child support order.

Provide the following information or documents by  ______________ (Date) :

 

 

 

The information or documents may be mailed or faxed. Your response to this subpoena must be dated, signed by you or your designee, and be either [ ] notarized OR [ ] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)."

As an authorized agent of a State or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any State. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws of your State. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency and reference the IV-D case number.

___________
(Date)

____________________________________
Authorized Agent

____________________________________
Print name, e-mail address, phone number and fax number

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control # 0970-0152 Expiration Date: 03/31/2004

 

Administrative Subpoena

TO: (1)
(Name, address)

 

Regarding: (2)
(name, DOB, SSN)

Case Caption: (3)

FROM: (4)
(CSE Agency, address, phone, e-mail address, fax number)

IV-D Case Number: (5)

Under Federal law (42 U.S.C. 666(c)(1)(B)) and similar statutes in this and all other States, you are required to provide financial or other information needed to establish, modify, or enforce a child support order.

Provide the following information or documents by _______(6)_______: (Date)

(7)

 

The information or documents may be mailed or faxed. Your response to this subpoena must be dated, signed by you or your designee, and be either [(8) ] notarized OR [(8) ] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)." (9)

As an authorized agent of a State or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any State. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws of your State. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency and reference the IV-D case number.

___________
Date

____________________________________
Authorized Agent (10)

____________________________________
Print name, e-mail address, phone number and
fax number (11)

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control # 0970-0152 Expiration Date: 03/31/2004

 

 

 

 

Instructions for the Administrative Subpoena

Purpose of this form: The Administrative Subpoena is the Federal form that the State IV-D programs, pursuant to section 454(9)(E) of the Social Security Act, are required to use in interstate cases. A State may elect to use this form in intrastate cases. This form is to be administratively issued by the IV-D program to subpoena financial or other information needed to establish, modify, or enforce a child support order.

To complete this form:

1. Place in the "TO" field the name and address of the individual or entity on whom you are serving the subpoena. (Frequently, this will be an employer.)

2. Place in the "REGARDING" field the name, date of birth, and SSN (if available) of the individual you are requesting information about. (Frequently, this will be the noncustodial parent.)

3. Place in the "CASE CAPTION" field the title of the proceeding (i.e., John Doe v. Jane Doe), under which you are issuing the subpoena.

4. Place in the "FROM" field Child Support Enforcement Agency name, address, phone number , e-mail address and fax number.

5. Provide the IV-D case number, or other case identifier, in the space following "IV-D Case Number"

6. Provide the date that the requested documents are to be provided to you.

7. Clearly, completely, and specifically describe all records or documents that you are requesting the individual receiving the subpoena provide.

8. Depending on your State law, check either the "NOTARIZED" box if you require notarized documents OR the "WITNESSED" box.

9. Place the date the subpoena is signed in the "DATE" field.

10. The person issuing the subpoena signs in the "AUTHORIZED AGENT" field.

11. Print name, e-mail address, phone number and fax number.