DEPARTMENT OF JUSTICE
DIVISION OF CHILD SUPPORT (DCS)
REQUEST FOR EXCEPTION
TO ELECTRONIC DISBURSEMENT ENROLLMENT
This form is being sent to you in response to your request to keep getting support payments by paper check. Please complete the
information below and mail this form to:
Department of Justice
Division of Child Support
P.O. Box 14320, Salem, OR 97309
PLEASE PRINT CLEARLY
137-055-6020(3)(b): DCS will disburse support payments by check when specific exceptions apply including the individual’s
special circumstances, which DOJ will review on a case by case basis based on the criteria of whether the issuance of a paper check
would be in the best interest of the child(ren).
Today’s Date:
Your Name:
Your Mailing Address:
Your City, State, and Zip Code:
Your County of Residence:
Please state the reason(s) why you believe getting your support payments electronically would not be in the best interest of the
child(ren):
Use additional sheets of paper, if necessary.
This section below is for use by the Oregon Child Support Program only.
DECISION REGARDING REQUEST FOR EXCEPTION
ELECTRONIC DISBURSEMENT ENROLLMENT
Date mailed:
This notice is to inform you that your request to keep getting support payments by paper check was reviewed by the Child
Support Program on and has been:
□ Approved. You will keep getting your support payments by paper check unless you voluntarily enroll in either Direct
Deposit or ReliaCard at a later date.
□ Denied. Pursuant to OAR 137-055-6020, you must get your support payments through either Direct Deposit in the bank
account of your choice, or the ReliaCard debit card. Fill out the enclosed enrollment form and mail it to the Department of
Justice, Division of Child Support, P.O. Box 14320, Salem OR 97309. If you do not make a choice within 30 days, you will
automatically be enrolled in the ReliaCard Debit Card Program.
Printed Name Title
Authorized Child Support Program Representative
Date of Decision
If you disagree with the decision, you have the right to file an appeal as provided in ORS 183.484. Your appeal must be filed
with the appropriate Oregon Circuit Court within 60 days from the date you receive this letter. You are also required to send a
copy of any appeal to the State of Oregon at the address on this form, and to the other party(ies).
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CSF 08 0701 (Rev. 11/13/08)
