Fillable Request for Review Modification, Change of Custody, Credit (Columbia Gorge Community College)

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Request for Review Modification, Change of Custody, Credit (Columbia Gorge Community College)

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Page 1 of 3 REQUEST FOR REVIEW MODIFICATION, CHANGE OF CUSTODY, CREDIT ON ARREARS OR TERMINATION
01 0142A web (Rev. 06/16/16)
STATE OF OREGON, Child Support Program, by the Administrator (ORS 25.010)
County: Court #: CSP #:
Participants:
Children:
Request for Review Modification, Change of Custody, Credit on Arrears or
Termination
By signing this form, I request the Child Support Program review my support order for the reasons
indicated below.
I know this request may change the order because the Program will apply the current child support
guidelines to my present circumstances. This may result in either parent being required to pay cash
child support, pay cash medical support and provide health care coverage. [OAR 137-050-0700 to 137-
050-0765]
I am requesting a review because:
It has been 35 months or more since the order was established or reviewed.
My circumstances have changed as indicated below.
Ma
rk and complete all that apply. Proof of any change must be provided or the request may be
denied. [OAR 137-055-3430]
I’ve had a significant change in my gross income, or have permanently lost my job.
When the order was entered my gross income was $ per month.
My gross income now is $ per month.
The other parent’s gross income has changed significantly from $ per month when the
last order was entered to $ per month at this time
Private health care coverage is now available, or the cost of private health care coverage has
changed.
Health care coverage is no longer available because:
There has been a significant change in the needs of the children. Explain:
Save
Print
Reset
, Obligor
, Obligee
, Other party (if any)
, (Child Attending School – if any)
, (Adult Child – if any)
Page 2 of 3 REQUEST FOR REVIEW MODIFICATION, CHANGE OF CUSTODY, CREDIT ON ARREARS OR TERMINATION
01 0142A web (Rev. 06/16/16)
There has been a change of custody for one or more of the children. Check all that apply:
I
don’t want child support from the other party. By choosing this option, I know the Program w
ill
no
t modify the order to have the other party pay support for at least 35 months unless there is
a
s
ubstantial change of circumstances.
I want child support from the other party. This request is my application for child support
services.
I want a credit against my arrears. I am asking for the credit because all the minor children have
be
en living with me since . [OAR 137-055-5510]
Please explain the custody change:
Please send any additional information or proof of the custody change with this request.
The children are legally emancipated. Explain:
The parent who owes support is incarcerated and has no known assets or income. You must
include the current mailing address for the correctional facility and the prisoner
identification number.
My financial circumstances have changed. Explain:
I now live with the other party and we are providing support for the children in our home.
I have children that weren’t included in the original order. List:
I now receive SSB SSD VA Benefits in the amount of $ per month.
My children receive $ per month from these benefits.
I request a credit against the child support arrears for SSB SSD Veterans Benefits paid
retroactively to the children in the amount of $ .
Complete and return a Uniform Income and Expense Statement (UIES) with this request. Send
any additional information or proof of the change with the UIES.
If y
ou have hired an attorney for child support issues, list their name, address and phone number:
Page 3 of 3 REQUEST FOR REVIEW MODIFICATION, CHANGE OF CUSTODY, CREDIT ON ARREARS OR TERMINATION
01 0142A web (Rev. 06/16/16)
If my request results in a legal action, I understand that legal documents will be sent to me by
regular mail at the address below.
Date Signature Printed Name
Cell #: Text? Yes No Message#:
Home #: Email:
Address City State Zip
We will use your address to send you documents. It may also appear in legal papers given to the other
party and in court records. If you do not want this address to be given to the other party or appear in
court records, please call us.
O
regon Child Support Program
PO Box 14680
Salem OR 97309
Telephone: 800-850-0228
FAX: 503-986-6284
TTY: 800-735-2900
T
he Child Support Program provides services for the State of Oregon. We cannot represent you or give
you legal advice. You may contact your own lawyer at any time. Low cost legal services may be
available. For information, you may visit our website at OregonChildSupport.gov.
Page 1 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
STATE OF OREGON, Child Support Program, by the Administrator (ORS 25.010)
County: Court #: CSP #:
Participants:
Children:
Uniform Income & Expense Statement
Date Signature Printed Name
Cell #: Text? Yes No Message#:
Home #: Email:
Address City State Zip
We will use your address to send you documents. It may also appear in legal papers given to the other party
and in court records. If you do not want this address to be given to the other party or appear in court records,
please call us.
List all ‘Joint Children’ in this Order (children under the age of 21, born to or adopted by the parties)
Name of Child
Date
of
Birth
Children Living With:
Other
Me Parent Other (Name)
Child 18-20 in
School
If Child 18, in
High School
Yes No
List your additional joint children on a separate sheet of paper.
Save
Print
Reset
, Obligor
, Obligee
, Other party (if any)
, (Child Attending School – if any)
, (Adult Child – if any)
Page 2 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
1. Jurisdiction Questions (
Only complete if no support order exists and the other parent does not reside in Oregon
)
This information will help us decide if the State of Oregon can legally establish a support order against the
other party, or if another jurisdiction will be requested to establish the order. If you answer yes to any of the first
four questions (1A-1D) for one or more of the children listed above, please continue to complete the entire
form, and return it to the office below. Please list all children for whom you are answering in the blank for each
question. If you answer no to all of the first four questions (1A-1D) for all children, please also complete 1E &
1D only and return this form to the office below. Different paperwork may be needed to request another
jurisdiction to establish the order.
1A. Was
your child (or children) conceived in Oregon?
Yes, List Child(ren) No
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
1B. Did your child (or children) ever live in Oregon with the other parent?
Yes, List Child(ren) No
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
1C. Did the other parent live in Oregon and pay prenatal expenses, birth costs, or support for
any of your children ?
Yes, List Child(ren) No
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
(name) Where (City/County) When (MM/YY)
What expenses did the other parent pay?
Who did the other parent pay?
1D. Did you and any of your children move here to be with the other parent?
Yes No
Did the other parent ask you to move here?
Yes No
1E. Have you ever received public assistance (cash or medical benefits) in another jurisdiction?
Yes, Where (City/County) When (Month/Year) No
1F. Do you already have a support order for any of these children? Yes No If yes, explain and
attach the most recent copy of your orders, if available:
Page 3 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
Support Order and Children Information
Do you already have a support order for these children? Yes No If yes, explain and attach the
most recent copy of your orders, if available:
Do you have a parenting time order or written parenting time agreement for these children?
Yes No If yes, attach a copy of the order or agreement.
Do you support other children in your home or have a support order for children not in your home?
Yes No If yes, list them below.
Child’s First Name
Date of
Birth
Relationship
(daughter,
son, etc.)
If there is an order for you to
pay support, provide state,
county & court number.
Child 18 in
High School in
Your Home
Yes No
List biological and adopted children or stepchildren you are ordered to support. List other children you support on a separate piece of paper.
Do y
ou pay or receive spousal support?
Yes No
Amount paid: $ to whom
Amount received: $ from whom
Employment, Income and Costs
Are you employed? Yes No
Name, address, & phone number of employer:
How many hours per week do you work? Do you consistently receive wages for overtime
hours? Yes No
What is your monthly income before deductions? $ . Attach a copy of your most recent
pay stub.
Do you pay mandatory union dues? Yes No If yes, how much per month? $
Do you receive expense reimbursements or allowances for a car, cell phone, housing, subsidies, or any
other expenses which reduce your living expenses? Yes No If yes, how much per month?
$ Attach proof you receive expense reimbursements or
allowances.
Are you receiving workers' compensation or unemployment benefits? Yes No
If yes, list the source and the amount of the monthly or weekly benefit:
Source: Amount: $ Monthly Weekly
Page 4 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
What type of work have you done in the last five years?
Why did your last job end?
Are you self-employed? Yes No
Name, address, & phone number of your business:
Attach a copy of your most recent tax return (personal and business, including all schedules) or
profit & loss statement.
Do you have other income?
Yes No Income includes but is not limited to, commissions,
advances, bonuses, dividends, severance pay, pensions, interest, Social Security benefits, disability
insurance benefits, prizes, lottery, alimony, Supplemental Security income, and distributions from a trust.
Income does not include child support, food stamp benefits, Social Security resulting from a child’s
disability, adoption assistance, guardianship assistance, and foster care subsidies.
Source: Amount: $
Source: Amount: $
Do you have child care costs for the ‘Joint’ children? Yes No
Are the children 12 years old or under? Yes No Are the children disabled? Yes No
If you answered yes to either question, list the name(s) of the children, date(s) of birth and amount(s)
you pay for their care and attach proof of child care costs: (Only include the costs you pay out of
pocket.)
Amount: $
Amount: $
Amount: $
Amount: $
Health Care Coverage and Medical Support
Are you paying for your own health care coverage? Yes No If yes, what is your monthly cost?
$ . Attach proof of coverage showing your monthly cost.
Is health care coverage available for your children? Yes No If yes, who insures the children?
Source of insurance: employer other group spouse domestic partner other
Insurance Co.: Phone #:
Address
Policy #: Group #: Effective date of the policy:
Monthly cost per child $ Name(s) of children currently covered by
insurance:
Do you pay ongoing medical expenses for the children? Yes No
If yes, list the name(s) of children, the reason for the expense, and the monthly cost:
Amount: $
Amount: $
Attach proof of insurance and ongoing medical expenses for the children.
Other Benefits, Costs, or Expenses
Do any of your children receive Social Security or Veteran’s benefits due to a parent=s disability
or retirement? Yes No
Page 5 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
What type of benefit do they receive?
Survivors and Dependents Educational Assistance
Social Security benefits
Apportioned Veteran’s benefits due to the disability or retirement of a parent
What is the total monthly benefit amount the children receive? $
If your child is in state care, do you have regular visits? Yes No
If so, how far do you travel?
How often do you visit?
Does the Department of Human Services pay any of these expenses? Yes No
Do y
ou have court ordered counseling or classes that you must attend? Yes No
If yes, what are your expenses associated with these classes? $
Do you have a medical condition that prevents you from working? Yes No
Attach proof of disability (SSA award letter, doctor’s diagnosis of disability)
Do you have court or attorney fees associated with the children in care? Yes No
If yes, list the fees:
Do you have to pay probation fees? Yes No If yes, how much? $
Are there any additional expenses or needs you want us to consider when calculating your child
support?
Amount of the expense: $ How does it affect your ability to pay support?
Additional Information
Are there any other special circumstances that you want us to consider?
Is there any information you can provide about the other parent?
If you need more room to answer any of these questions, attach a separate piece of paper
Ar
e you represented by an attorney for child support matters? Yes No
If yes, please provide the attorney name and contact information below.
Attorney Name Phone # Fax #
Address City/State Zip
Page 6 of 6 UNIFORM INCOME AND EXPENSE STATEMENT
01 0100 web (Rev. 09/23/19)
English
Need another language? Contact us.
French
Avez-vous besoin d’une autre langue? Communiquez avec nous.
German
Sie benötigen eine andere Sprache? Kontaktieren Sie uns.
Russian
Предпочитаете другой язык? Свяжитесь с нами.
Somali
Ma u baahan tahay luqad kale? Na la soo xiriir.
Spanish
¿Necesita otro idioma? Contáctenos.
Vietnamese
Quý vị có cần dùng ngôn ngữ khác không? Hãy liên lạc với chúng tôi.
T
he Child Support Program provides services for the State of Oregon. We cannot represent you or give you
legal advice. You may contact your own lawyer at any time. Low cost legal services may be available. For
information, you may visit our website at OregonChildSupport.gov.
O
regon Child Support Program
PO Box 14680
Salem OR 97309
Telephone: 800-850-0228
FAX: 503-986-6284
TTY: 800-735-2900
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Request for Review Modification, Change of Custody, Credit (Columbia Gorge Community College)

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Completed 12 March 2021

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