Request For An Administrative Review Of The Support Order Page 2
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4Montgomery County CSEA
14 W Fourth St, PO Box 8744
Dayton, OH 45401-8744
937-225-4600
1-800-555-0430
Name:_____________________________________
Address:___________________________________
__________________________________________
Date:
________________________________
Case Number:
_______________________
Obligor:
________________________________
Order Number:
_______________________
Obligee:
________________________________
Request for an Administrative Review
of the Support Order
I request an administrative review and adjustment of my child support order as set forth in OAC 5101:12-60-05.1 for the following
reason (please check the appropriate box):
It has been at least 36 months since the date of the most recent support order.
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My child support order was last ordered or reviewed for an adjustment less than 36 months ago. I have marked the appropriate
circumstance(s) which has changed. I have attached any required evidence of the change in circumstance(s) to this form.
1.
The existing order established a minimum or a reduced amount of support based on the Child Support
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Guidelines (hereafter “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.
2.
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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.
3.
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I am
The other party is unemployed due to a plant closing or mass layoff as defined in the Worker
Adjustment and Retraining Notification Act (WARN), 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.
4.
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I am
The other party is permanently disabled reducing his or her earning ability. The requester 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.
5.
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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.
6.
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I have
The other party has experienced a thirty per cent 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.
JFS 01849 (Eff. 07/2005)
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