Page 1 of 2 - CHILD SUPPORT GRIEVANCE FORM
CSF 01 8643 (Rev. 01/04/12)
Child Support Grievance Form
If you have a dispute with a child support office, please try to resolve the problem with staff or supervisors in
that office before you file a grievance (formal complaint). Each local office should have a complaint process for
you to use. The child support office cannot discriminate against you for filing a complaint or grievance.
If you believe you were treated unfairly or your support case was not handled the right way, and you are
unable to resolve your complaint through your local office, report it on this form. Send the completed form to:
Constituent Liaison, Child Support Program, 1162 Court Street NE, Salem, OR 97301.
Your name: Daytime Phone:
Case Name (if different) Child Support Case Number:
Address:
(Street)
(City) (State) (Zip Code)
PLEASE READ THIS PART BEFORE FILING A GRIEVANCE:
The Child Support Program must follow the requirements of federal and state laws when deciding and taking
actions. We realize that sometimes people do not agree with these actions or decisions. However, if your
complaint is about an action the law says we must do or can do, we cannot continue with your grievance
using this formal process. We will keep working with you to resolve the issue(s). Some examples of issues
we cannot address using this formal process include child support order amounts, income withholding as
required by law, and actions taken by other agencies or states. For more specific information see OAR
137-055-1600.
Oregon Child Support office you want to report:
Describe your complaint here. Be sure to sign and date the form on the next page.
NOTE: This form is compatible with Acrobat Reader v8
or higher. If the 'Send' button doesn't work (by opening
an email message), select 'Save As' to save the completed
form locally and then attach it to an email message
addressed to: Constituent.Desk@doj.state.or.us
