Form Cse-1178a Forff - The Modification Documents Packet Page 4
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14ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CSE-1172A FORFF (5-17)
Division of Child Support Services
REQUEST FOR MODIFICATION CHECKLIST
NAME
ATLAS NO.
I am requesting a modification as a result of the following substantial or continuing change (check all that apply):
Substantial Change: A change that would result in an increase or decrease of your current support order.
Continuing Change: A change that would occur continuously for six months or longer.
Note: One time inheritances or a one time bonus are not considered substantial and/or continuing changing events.
My order was established or last modified more than 3 years ago.
Change in Employment/Income.
Loss of Job (Date last job ended)
You have been unemployed at least 30 days, with the expectation that it will continue another 90 days.
Incarceration (Dates of Incarceration): From
to
.
Determination of Disability.
Continuous change in legal decision making/custody or parenting time.
One or more children have emancipated.
Birth of additional children to support.
Change in child-related expenses (e.g., child care).
Medical Changes:
Premium cost
Loss of coverage
The party providing insurance coverage changed
Your modification request must include this Request for Modification Checklist (CSE-1172A), a Request for
Modification Review (CSE-1170A), a completed Affidavit of Financial Information (CSE-1171A), and a notarized
Agreement to Accept Service by Mail (CSE-1167A).
If your order is more than three years old, you have the right to request a modification of your order without showing a
change in circumstance that is substantial and continuing. However, all requests where orders are less than three years
old, must fit the modification criteria as outlined above or your case may not be eligible for DCSS to file the modification.
Child support orders from other states may not necessarily be modified in Arizona and may take longer to process.
Your case may not qualify for a modification, if:
•
The youngest child emancipates in less than one year.
•
The other parent is not located.
•
The current order is zero due to incarceration/disability and the other party is still incarcerated/disabled.
If your case does not qualify for a modification review by DCSS, you still may be able to request a modification on your
own through the appropriate court.
MONITOR THE PROGRESS OF YOUR CASE AT:
https://des.az.gov/services/child-and-family/arizona-child-support-services
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