Notice Of Determination Of Controlling Order
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4NOTICE OF DETERMINATION OF CONTROLLING ORDER
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Date
IV-D Non Public Assistance
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IV-D Non PA Medicaid
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Obligor
Full Services
(First, Mid, Last)
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Medical Services Only
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Obligee
IV-D Public Assistance
(First, Mid, Last)
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IV-E Foster Care (IV-D Case)
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Non-IV-D
File Stamp
To:
(Agency Name and Address)
FIPS Code ________________________ State __________________________
IV-D Case No. ______________________________________________________
Docket No. _________________________________________________________
From:
(Contact Person, Agency, Address, Phone, Fax, Internet)
FIPS Code _________________________ State _________________________
IV-D Case No. ______________________________________________________
Docket No. _________________________________________________________
1. On
,
determined
(Date)
(Tribunal Name; County, State)
which order to recognize for prospective enforcement. The following orders were considered:
#
County
State
Date of Order
IV-D Case Number
Docket Number
Order Type
1
2
3
4
5
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Additional orders listed on attached sheet.
2. The tribunal determined that order number ________ listed above in the table is the controlling order for prospective
enforcement.
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3.
A copy of a modified order is attached.
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The tribunal determined that none of the existing orders is the controlling order. Therefore, a new
order was entered; a copy is attached.
4. $_______________ per ____________________________
is the current charging amount.
(Frequency)
5. The tribunal calculated arrears to be $________________ as of ______________________________
.
(Date)
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Attached is a copy of the worksheet(s) showing the arrears calculation.
6. A copy of this notice (and any new or modified order) was also sent to:
_______________________________________________________________________________________________
Entity Name; State
_______________________________________________________________________________________________
Entity Name; State
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Obligor
Obligee
Additional Entities Listed on Attached Sheet
Notice of Determination of Controlling Order
OMB No. 0970 - 0085
Page 1 of 1
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