Request For An Administrative Review Of The Support Order

<County Name-if known> County CSEA <CSEA Address 1-if known> <CSEA Address 2-if known> <CSEA City, State, ZIP-if known> Telephone Number: Toll Free Number: Fax Number: <CSEA Local phone #-if known> <CSEA 800 #-if known> <CSEA Fax #-if known> <Requester's first and last name> <Requestor Address 1> <Requestor Address 2> <Requestor City, State, Zip> Case Number: Order Number: <SETS number> <order number> Date: <print date> Child Support Obligor: <Obligor's name> Child Support Obligee: <Obligee's name> Request for an Administrative Review of the Child Support Order I request an administrative review and adjustment of my child support order, including the medical support provisions and any arrears payments, as set forth in Ohio Administrative Code (OAC) rules 5101:12-60-05 to 5101:12-60-05.6 for the following reason (please check the appropriate box): It has been at least 36 months since the date of the most recent child support order. It has been less than 36 months ago since the date of the most recent child support order. I have marked the appropriate circumstance which has changed. I have attached any required evidence of the change in circumstance to this form. [If the required document is not submitted to the Child Support Enforcement Agency (CSEA) with this request, your request will be denied.] 1. The existing order established a minimum or a reduced amount of support based on the Child Support Guidelines due to the unemployment or underemployment of the obligor and the obligor is no longer unemployed or underemployed. The requesting party must provide to the CSEA relevant evidence or information supporting an allegation of the change in the obligor's employment status. I am The other party is unemployed or laid off, the unemployment or lay off is beyond the party's control, and the unemployment or lay off has continued uninterrupted for thirty consecutive days. The party requesting the administrative review must provide to the CSEA relevant evidence of the unemployment or layoff, including that the unemployment or lay off is beyond the party's control. If the amount of the existing support order was calculated based on the annualized income of an individual who is employed in a seasonal occupation, and the cause of the request for a review is a seasonal lay off, then the party does not meet the criteria for an administrative review under this section. I am The other party is unemployed due to a plant closing or mass layoff as defined in the Worker Adjustment and Retraining Notification (WARN) Act, 29 U.S.C. §2101 et seq. The administrative review request may only be made after the worker's last day of employment. The worker must provide to the CSEA a copy of the notice of the plant closing or mass layoff provided pursuant to the WARN Act. I am The other party is permanently disabled reducing his or her earning ability. The requestor must provide to the CSEA verification of receipt of benefits administered by the Social Security Administration due to the disability and/or a physician's complete diagnosis and permanent disability determination. I am The other party is institutionalized or incarcerated and cannot pay support for the duration of the child's minority and no income or assets are available to the party which could be levied or attached for support. The requestor must provide evidence of the institutionalization or incarceration and the inability to pay support during the child's minority. 2. 3. 4. 5. JFS 01849 (Rev. 2/2009) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. I have The other party has experienced a thirty percent decrease, which is beyond the party's control, or a thirty per cent increase in gross income or income-producing assets for a period of at least six months and which can reasonably be expected to continue for an extended period of time. The party requesting the administrative review must provide to the CSEA relevant evidence or information supporting an allegation of a change in status. The child support order is not in compliance with the Ohio Child Support Guidelines due to the termination of the support obligation for a child of the existing support order. I have children by the same parent in two or more administrative child support orders and I want to combine the orders into a single administrative child support order. I want to access available or improved private health insurance coverage that is available for the child. The requesting party must provide to the CSEA relevant evidence or information supporting the allegation that access to new or improved private health insurance is available. I have The other party has experienced an increase or decrease in the cost of ordered private health insurance coverage or child care for the child which is expected to result in a change of more than ten percent to the child support obligation based on the current Child Support Guidelines calculation. The requesting party must provide to the CSEA relevant evidence or information supporting an allegation of an increase or decrease in the cost of private health insurance or child care. If the request is based on a change in the cost of private health insurance, the requesting party must provide to the CSEA evidence regarding the cost of a family plan and the cost of an individual plan. The private health insurance that is currently being provided in accordance with the child support order is no longer reasonable in cost and/or accessible. The requesting party must provide to the CSEA relevant evidence or information supporting an allegation that the private health insurance is no longer reasonable in cost and/or accessible. I am the obligor and I assert that my annual gross income is now below 150% of the federal poverty level and I should not be ordered to pay cash medical support (the federal poverty guidelines can be found at http://www.aspe.hhs.gov/poverty or by contacting the CSEA). The obligor must provide to the CSEA relevant evidence or information supporting an allegation that his or her annual gross income is below 150% of the federal poverty level. I am the obligor and I am a member of the uniformed services who has been called to active service for a period of more than thirty (30) days. If I have checked this box, I have attached a military Power of Attorney to permit a designated person to act on my behalf in the administrative review. A temporary adjustment order pursuant to OAC rule 5101:12-60-05.2 was issued, the obl