Commonwealth of Virginia
Department of Social Services
Division of Child Support Enforcement
REQUEST FOR REVIEW AND ADJUSTMENT
_______________________________ DCSE Case No. ___________________
Please read this information before submitting the attached request for a review. If DCSE is sending you this because you have
requested a review, you must complete and return the attached request form within 5 days from the date of this notice, or the request
will be denied. If you have any questions or need help completing this form contact the district office that handles your case.
If it has been three years since your child support order was entered, modified, or reviewed, you may request a review. Complete the
attached request form indicating this to be the reason you want your child support order reviewed.
f it has been LESS than three years since your child support order was entered, modified, or reviewed, there must be a special
circumstance reason to justify the request. Review the special circumstance reasons that qualify for a possible adjustment of the child
support amount. The reasons and documentation requirements are:
A child needs to be added to your order as a result of a birth or a physical change in custody. Provide the name and date of birth of
the child and the reason for the request.
A child is no longer eligible to receive continued current support due to a physical change in custody or emancipation (and other
children are active on the order). Provide the name and date of birth of the child and the reason for the request.
The health care coverage insurance premium increases or decreases by at least 25 percent. Provide a statement from the insurance
carrier or employer that specifies the child or children’s cost of the premium to the insured with this request. You may provide the
current and previous costs of the child or children’s premium in writing on the request, but only if a statement from the insurance
carrier or employer cannot be obtained.
The existing child support order does not include an unreimbursed medical/dental provision. No documentation is necessary.
Either parent’s income increases or decreases by at least 25 percent. Submit the last three pay stubs, an income earning statement
from the employer, or any other form of income verification available to you with this request. If you have become unemployed,
you must provide proof that your loss of employment is not voluntary, meaning that you did not quit your job without good cause or
you were terminated (fired) with cause. You may provide a statement from the employer or other credible source to prove you are
involuntarily unemployed. If you qualify to receive unemployment benefits, you may provide a copy of the approval notice from
Virginia’s or another states’ Employment Commission as proof you are involuntarily unemployed.
A health care coverage obligation needs to be added to the order. No documentation is necessary.
Either parent is a Reservist or National Guard personnel experiencing a change of income due to recall to active duty. Provide any
document that supports a return to active duty with this request.
The work-related child care expenses increase or decrease by at least 25 percent. Submit a statement from the child care provider
that specifies the cost of the child care and the name(s) of the child(ren) the provider cares for.
DCSE will conduct a review if a special circumstance applies to the other party and you cannot obtain the required documentation.
You, as the requesting party however, must provide an explanation of the o
ther party’s special circumstance:
APECS 222 Rev. 5/06