State Referral: Federal Criminal Prosecution For Non-Support Form - Project Save Our Children - Office Of Child Support Enforcement Page 5

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STATE REFERRAL FEDERAL CRIMINAL PROSECUTION
FOR NON-SUPPORT (18 U.S.C. §228)
Professional License:
Enter the type of license that the payer may have such as doctor, nurse,
contractor, etc.
Auto & Driver’s License/State:
Enter the driver’s license information of the payer if known. (If only the state
is known, please enter it.)
Alias:
Enter the aliases that the payer may have used or is currently using.
Does the Payer have any current
Enter the type of warrant and the state or jurisdiction that issued the
warrants?
warrant, if known.
Physical Description:
Describe the payer (race, sex, height, weight, eyes, hair color, tattoo etc)
SECTION 2 – ORDER INFORMATION
Date Order was
Entered:*
Enter the date the order was issued. Format MM/DD/YYYY.
Amount Ordered:
Enter the amount that was ordered. You just need to enter the numbers and
cents (Format 0000.00). This field will automatically show it in common
currency amounts.
Arrearage:*
Enter the amount that the payer is in arrears.
Arrears from Date:
Enter the date that the arrears started from. Format MM/DD/YYYY.
Arrears to Date:
Enter the date that the arrears were last certified. Format MM/DD/YYYY.
When was the Last Payment?:
Enter the date of the last payment received from the payer. Format
MM/DD/YYYY.
Payment History & Order:
These documents must be attached to the referral.
SECTION 3 – REFERRAL
INFORMATION* (This section must be filled out completely.)
State / County:
Enter the abbreviation for the state that is submitting the referral. If the
referral originated from a county, enter the name of the county.
Name of Referring Agency:
Enter the name of the referring agency. (e.g., state CSE, AUSA, OIG)
Referral Date:
Date that the referral is sent to PSOC Coordinator.
State Contact Person:
Enter the name of a person that can be contacted if the coordinator has
questions concerning the referral.
Direct Phone Number:
Enter the telephone number for the contact person.
FAX:
Enter the fax number for the contact person.
Address of Referring Agency:
Enter the mailing street address of the contact person that will receive the
case after the case has been processed.
Email address:
Enter the contact person’s email address.
City:
Enter the city of the contact person.
State:
Enter the state of the contact person.
Zip Code:
Enter the mailing zip code of the contact person.
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