Form Cse-1178a Forff - The Modification Documents Packet Page 3
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14ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CSE-1170A FORFF (5-17)
Division of Child Support Services
REQUEST FOR MODIFICATION REVIEW
ATLAS No:
Si usted habla y lee solamente español, por favor llame a la oficina y pida a un representante que habla español.
The Division of Child Support Services (DCSS) can review your child support case for the possibility of a modification
to your court order.
In order for the review to take place, you must complete all of the following documents: the Affidavit of Financial
Information (CSE-1171A), the Agreement to Accept Service by Mail (CSE-1167A), and the Request for
Modification Checklist (CSE-1172A). You must sign the Agreement to Accept Service by Mail (CSE-1167A)
in front of a notary. A modification review will not begin until these completed, notarized documents are received
by DCSS. Notary services are provided free of charge at your local DCSS office.
Medical support is a required provision for all child support orders. You must supply all policy numbers, group
numbers and cost information if you are providing health insurance for your children (other than government
provided insurance such as AHCCCS or Kids Care). This information must be completed on page 4 of the enclosed
Affidavit of Financial Information (CSE-1171A). If there is no medical insurance coverage, a cash medical
order may be added to the current child support order.
If you would like assistance in completing your documents, DCSS conducts modification workshops for parents
with open DCSS cases on the first Thursday of every month in Maricopa County offices or upon request. Additional
information on modifications can be found at the DCSS web site:
https://des.az.gov/services/child-and-family/child-support/arizona-child-support-services-modify-and-calculate-child
A court hearing may not be needed. Both parties may sign a legal agreement (stipulation) to an order. If both parties
agree to a proposed order please contact your local office to obtain an appointment with DCSS.
Please provide the following information and return this form with your completed Agreement to Accept Service
by Mail (CSE-1167A), Affidavit of Financial Information (CSE-1171A) and the Request for Modification
Checklist (CSE-1172A).
Your Name:
Your Current Address:
Your Home Phone Number:
Your Cell Phone Number:
Your Work Phone Number:
Other Parties Address:
Other Parties Phone Number:
Date of last contact with other party:
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination
Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits
discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex,
national origin, age, disability, genetics and retaliation. To request this document in alternative format or for further
information about this policy, contact the Division of Child Support Services at (602) 252-4045; TTY/TDD Services:
7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en línea o
en la oficina local.
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