7/23/2019 Order Modification Form

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Hamilton County CSEA Telephone Number: 513-946-737

!!! E" Central #ar$%ay Toll &ree Number: 1-''-315-7119

Cin(innati) *H 45!'! &a+ Number: 513-946-!396

,e.ue/ter0/ ir/t an2 la/t name,e.ue/tor A22re// 1

,e.ue/tor City) State) ip

ate: ,print 2ate

Ca/e Number: ,SETS number Chil2 Support *blior: ,*blior0/ name

*r2er Number: ,or2er number Chil2 Support *bliee: ,*bliee0/ name

Request for an Administrative Reviewof the Child Support Order

re.ue/t an a2mini/trati8e re8ie% an2 a2u/tment o my (hil2 /upport or2er) in(lu2in the me2i(al /upport pro8i/ion/ an2 any

arrear/ payment/) a/ /et orth in *hio A2mini/trati8e Co2e *AC; rule/ 51'1:1!-6'-'5 to 51'1:1!-6'-'5"6 or the ollo%in

rea/on plea/e (he($ the appropriate bo+;:

t ha/ been at lea/t 36 month/ /in(e the 2ate o the mo/t re(ent (hil2 /upport or2er"

t ha/ been less than 36 month/ ao /in(e the 2ate o the mo/t re(ent (hil2 /upport or2er" ha8e mar$e2 the appropriate(ir(um/tan(e %hi(h ha/ (hane2" ha8e atta(he2 any re.uire2 e8i2en(e o the (hane in (ir(um/tan(e to thi/ orm" <If the

required document is not submitted to the Child Support Enforcement Agency (CSEA with this request! your

request will be denied"=

1" The e+i/tin or2er e/tabli/he2 a minimum or a re2u(e2 amount o /upport ba/e2 on the Chil2 Support

>ui2eline/ 2ue to the unemployment or un2eremployment o the oblior an2 the oblior i/ no loner

unemploye2 or un2eremploye2" The re.ue/tin party mu/t pro8i2e to the CSEA rele8ant e8i2en(e orinormation /upportin an alleation o the (hane in the oblior0/ employment /tatu/"

!" am The other party i/ unemploye2 or lai2 o) the unemployment or lay o i/ beyon2 the party?/

(ontrol) an2 the unemployment or lay o ha/ (ontinue2 uninterrupte2 or thirty (on/e(uti8e 2ay/" The party

re.ue/tin the a2mini/trati8e re8ie% mu/t pro8i2e to the CSEA rele8ant e8i2en(e o the unemployment or

layo) in(lu2in that the unemployment or lay o i/ beyon2 the party?/ (ontrol" the amount o the e+i/tin/upport or2er %a/ (al(ulate2 ba/e2 on the annuali@e2 in(ome o an in2i8i2ual %ho i/ employe2 in a /ea/onal

o((upation) an2 the (au/e o the re.ue/t or a re8ie% i/ a /ea/onal lay o) then the party 2oe/ not meet the

(riteria or an a2mini/trati8e re8ie% un2er thi/ /e(tion"

3" am The other party i/ unemploye2 2ue to a plant (lo/in or ma// layo a/ 2eine2 in the or$er

A2u/tment an2 etrainin Notii(ation AN; A(t) !9 B"S"C" !1'1 et /e." The a2mini/trati8e re8ie%

re.ue/t may only be ma2e ater the %or$er?/ la/t 2ay o employment" The %or$er mu/t pro8i2e to the CSEA a(opy o the noti(e o the plant (lo/in or ma// layo pro8i2e2 pur/uant to the AN A(t"

4" am The other party i/ permanently 2i/able2 re2u(in hi/ or her earnin ability" The re.ue/tor mu/t pro8i2e to the CSEA 8erii(ation o re(eipt o beneit/ a2mini/tere2 by the So(ial Se(urity A2mini/tration 2ue

to the 2i/ability an2Dor a phy/i(ian0/ (omplete 2iano/i/ an2 permanent 2i/ability 2etermination"

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7/23/2019 Order Modification Form

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5" am The other party i/ in/titutionali@e2 or in(ar(erate2 an2 (annot pay /upport or the 2uration o the

(hil20/ minority an2 no in(ome or a//et/ are a8ailable to the party %hi(h (oul2 be le8ie2 or atta(he2 or

/upport" The re.ue/tor mu/t pro8i2e e8i2en(e o the in/titutionali@ation or in(ar(eration an2 the inability to

 pay /upport 2urin the (hil20/ minority"

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7/23/2019 Order Modification Form

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6" ha8e The other party ha/ e+perien(e2 a thirty per(ent 2e(rea/e) %hi(h i/ beyon2 the party0/ (ontrol) or

a thirty per (ent in(rea/e in ro// in(ome or in(ome-pro2u(in a//et/ or a perio2 o at lea/t /i+ month/ an2

%hi(h (an rea/onably be e+pe(te2 to (ontinue or an e+ten2e2 perio2 o time" The party re.ue/tin the

a2mini/trati8e re8ie% mu/t pro8i2e to the CSEA rele8ant e8i2en(e or inormation /upportin an alleation o a(hane in /tatu/"

7" The (hil2 /upport or2er i/ not in (omplian(e %ith the *hio Chil2 Support >ui2eline/ 2ue to the termination o 

the /upport obliation or a (hil2 o the e+i/tin /upport or2er"

" ha8e (hil2ren by the /ame parent in t%o or more a2mini/trati8e (hil2 /upport or2er/ an2 %ant to (ombinethe or2er/ into a /inle a2mini/trati8e (hil2 /upport or2er"

9" %ant to a((e// a8ailable or impro8e2 pri8ate health in/uran(e (o8erae that i/ a8ailable or the (hil2" The

re.ue/tin party mu/t pro8i2e to the CSEA rele8ant e8i2en(e or inormation /upportin the alleation that

a((e// to ne% or impro8e2 pri8ate health in/uran(e i/ a8ailable"

1'" ha8e The other party ha/ e+perien(e2 an in(rea/e or 2e(rea/e in the (o/t o or2ere2 pri8ate health

in/uran(e (o8erae or (hil2 (are or the (hil2 %hi(h i/ e+pe(te2 to re/ult in a (hane o more than ten per(entto the (hil2 /upport obliation ba/e2 on the (urrent Chil2 Support >ui2eline/ (al(ulation" The re.ue/tin party

mu/t pro8i2e to the CSEA rele8ant e8i2en(e or inormation /upportin an alleation o an in(rea/e or 2e(rea/e

in the (o/t o pri8ate health in/uran(e or (hil2 (are" the re.ue/t i/ ba/e2 on a (hane in the (o/t o pri8ate

health in/uran(e) the re.ue/tin party mu/t pro8i2e to the CSEA e8i2en(e rear2in the (o/t o a amily plan

an2 the (o/t o an in2i8i2ual plan"

11" The pri8ate health in/uran(e that i/ (urrently bein pro8i2e2 in a((or2an(e %ith the (hil2 /upport or2er i/ noloner rea/onable in (o/t an2Dor a((e//ible" The re.ue/tin party mu/t pro8i2e to the CSEA rele8ant e8i2en(e or 

inormation /upportin an alleation that the pri8ate health in/uran(e i/ no loner rea/onable in (o/t an2Dor 

a((e//ible"

1!" am the oblior an2 a//ert that my annual ro// in(ome i/ no% belo% 15'F o the e2eral po8erty le8el an2

/houl2 not be or2ere2 to pay (a/h me2i(al /upport the e2eral po8erty ui2eline/ (an be oun2 at

http:DD%%%"a/pe"hh/"o8Dpo8erty or by (onta(tin the CSEA;" The oblior mu/t pro8i2e to the CSEA rele8ante8i2en(e or inormation /upportin an alleation that hi/ or her annual ro// in(ome i/ belo% 15'F o the

e2eral po8erty le8el"

13" am the oblior an2 am a member o the uniorme2 /er8i(e/ %ho ha/ been (alle2 to a(ti8e /er8i(e or a perio2

o more than thirty 3'; 2ay/" ha8e (he($e2 thi/ bo+) ha8e atta(he2 a military #o%er o Attorney to

 permit a 2e/inate2 per/on to a(t on my behal in the a2mini/trati8e re8ie%"

14" A temporary a2u/tment or2er pur/uant to *AC rule 51'1:1!-6'-'5"! %a/ i//ue2) the oblior?/ term o a(ti8e

military /er8i(e ha/ en2e2) an2 the oblior ha/ pro8i2e2 the CSEA %ritten 2o(umentation /ui(ient to e/tabli/hthat the oblior0/ employer ha/ 8iolate2 the Bniorme2 Ser8i(e/ Employment an2 eemployment iht/ A(t)

3 B"S"C" 43'1 to 4333"

*hio la% re.uire/ that a lo(al CSEA pro8i2e (hil2 /upport enor(ement /er8i(e/ on all (hil2 /upport (a/e/) in(lu2in the re8ie%an2 a2u/tment o a (hil2 /upport or2er" Ho%e8er) a G- (a/eG i/ eliible or a22itional /er8i(e/ that are not a8ailable to a

Gnon-- (a/e"G you ha8e a Gnon-- (a/e)G you may (onta(t the CSEA or inormation about (ompletin a - appli(ation"

ithin 15 2ay/ o re(ei8in your re.ue/t or an a2mini/trati8e re8ie% an2 a2u/tment an2 any re.uire2 e8i2en(e) the CSEA %ill

re8ie% your re.ue/t an2 2etermine %hether a re8ie% /houl2 be (on2u(te2" Ioth partie/ to the or2er %ill be notiie2 o the 2atean2 lo(ation o the a2mini/trati8e re8ie%" The noti(e %ill be maile2 to the la/t $no%n a22re// o both partie/" The notii(ation %ill

al/o re.ue/t that you pro8i2e inan(ial inormation) me2i(al /upport inormation) an2 any other inormation ne(e//ary to properly

re8ie% the (hil2 /upport or2er" your re.ue/t i/ 2enie2) the CSEA %ill /en2 you noti(e o the 2enial"

#lease be aware that you may not dismiss your request for an administrative review on or after the scheduled review date"

Also! requesting an administrative review may result in the monthly support obligation increasing! decreasing! or

remaining the same or in a change in the medical support provisions"

#JEASE JST AJJ *CBKENTS THAT L*B ATTACHE:

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 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 

 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 

 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 

 Sinature o e.ue/tor 

 #rinte2 Name o e.ue/tor 

#lea/e pro8i2e your (urrent a22re// i 2ierent rom pae 1:

A22re//: MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMate

 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

aytime Telephone Number 

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