Fillable Request for Review and Adjustment Online Forms Instructions (Virginia Department of Motor Vehicles)

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Request for Review and Adjustment Online Forms Instructions (Virginia Department of Motor Vehicles)

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Request for Review and Adjustment
Online Forms Instructions
• Complete the Review and Adjustment packet which includes the following
documents:
o Request for Review and Adjustment
o Financial Form
o Health Insurance Verification Form (if the you are the custodial
parent)
• Scan or take a photo of the completed forms and additional required
documents and email to askdcse@dss.virginia.gov
.
• A review and adjustment specialist will contact you to confirm receipt of
your documents and gather any further needed information.
Commonwealth of Virginia
Department of Social Services
Division of Child Support Enforcement
REQUEST FOR REVIEW AND ADJUSTMENT
________________________________ Date____________________________
Name
_______________________________ DCSE Case No. ___________________
Address
________________________________
Address
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.
I
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
NOTICE:
Yo
u must indicate the reason for the request. Requests for reviews because of changes in circumstances must qualify as one o
f
th
e special circumstances reasons listed on this form. Clearly state the special circumstances reason and provide the required
documentation. DCSE will not accept any requests that do not indicate the reason for the request, and the request must include
d
ocumentation as required.
Once a request for Review and Adjustment has been received, it may only be withdrawn by written request. However, the non-
requesting party can object to the withdrawal and action to complete the review will continue.
A
review could result in an upward or a downward modification or indicate no modification is warranted at this time.
To request a review, complete and sign the Request for Review and Adjustment below and return it to the District Office that handles
your case. If DCSE has sent you this notice because you have requested a review, you must complete and return the request within 5
days from the date of this notice or the request will be denied.
**DETACH AND MAIL**
---------------------------------------------------------------------------------------------------------------------------------------------------------------
REQUEST FOR REVIEW AND ADJUSTMENT
I
,__________________________________________________________ ,am requesting a review because:
____________________________
________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
______________________________________ ___________________________________________
Printed Name / DCSE Case #: Address
______________________________________ ___________________________________________
Sig
nature Address
RETURN THIS REQUEST TO THE DCSE OFFICE HANDLING YOUR CASE.
BE SURE TO INCLUDE DOCUMENTATION AS REQUIRED.
APECS 222 Rev. 5/06
click to sign
signature
click to edit
Commonwealth of Virginia
Department of Social Services
Division of Child Support Enforcement
I058-02-2018 Page 1 of 5 Barcode
FINANCIAL STATEMENT
DATE:
Division Case Number:
The Financial Statement is used to determine the proper amount of child support for your case. It is important to return
this document along with proof of income and expenses within the specified time frame in order to receive proper
credit on the support obligation worksheet.
SECTION A: HOUSEHOLD/SUPPORT ORDER INFORMATION
CP/NCP FIRST NAME MIDDLE NAME LAST NAME
Social Security Number:
Date of Birth:
Mailing Address:
City, State, Zip:
Residential Address:
(if different)
Phone
Home:
Work:
Cell:
Email address:
Your nearest living relative:
Relationship:
Relative’s Address:
City, State, Zip Code:
Phone:
Names of dependents in this case:
Dependents living with you for whom you are the biological or adoptive parent:
Child’s Name
Birth Date
Relationship
Other persons presently supported by you under any court or administrative order:
Name
Address
Birth Date
Relationship
Order Date/Type
Payee
Ordered Amount
Total Amount Paid
(Court or
Administrative)
(Person you pay)
($ amt and pay
frequency)
(Over last 6 months)
To receive credit for the above payments, you must provide proof such as pay stubs, receipts from the custodial parent
on the case, or other documents that verify payments.
I058-02-2018 Page 2 of 5 Barcode
If you pay or receive spousal support/alimony, provide the following information:
Order Date
Issuing Court
$
Amount/Frequency
Paid to/Received
from
SECTION B: INCOME / EMPLOYMENT
Are you self-employed?
Yes No
NOTE: If you are self-employed, you must submit your most current tax return including all Schedules, as well as
a record of all self-employment tax you have paid this calendar year. Self-employed individuals may be entitled
to deductions from their gross monthly income that can only be determined if you provide this information.
Employer:
Employment Date:
Employer’s Address:
City, State, Zip Code:
Employer Phone:
Occupation:
Hourly Rate:
Pay Frequency (check one):
Weekly Bi-weekly Semi-monthly (twice/month) Monthly
Do you receive overtime pay? Yes
No
Gross pay per period:
(amount paid before deductions including overtime/shift
differential pay if applicable)
Do you have a 2
nd
job? Yes No
If yes, provide secondary employer information:
Employer:
Employment Date:
Employer’s Address:
City, State, Zip Code:
Employer Phone:
Occupation:
Hourly Rate:
Pay Frequency (check one):
Weekly Bi-weekly Semi-monthly (twice/month) Monthly
Do you receive overtime pay? Yes
No
Gross pay per period:
(amount paid before deductions including overtime/shift
differential pay if applicable)
Important: Attach copies of your 3 most recent pay stubs or a written statement from your employer(s)
verifying your average gross monthly income.
Do you receive income from any other source? Yes
No
Monthly amount:
Income is defined as salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions,
interest, trust income, annuities, capital gains, social security benefits, workers’ compensation benefits,
unemployment insurance benefits, disability insurance benefits, veteran’s benefits, spousal support, rental
income, gifts, prizes or awards.
Current gross monthly income (total amount of income from all sources indicated
above):
Total income over last 12 months (total amount of all W-2’s):
I058-02-2018 Page 3 of 5 Barcode
Past employment and periods of unemployment: List all previous employers and periods of unemployment for
the last 12 months:
Name
Address
Gross
Monthly
Income
Employment
Dates
SECTION C: HEALTH INSURANCE
Please provide proof of insurance and insurance costs.
Is health insurance available at your place of employment? Yes No
Do you have health insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
Is vision insurance available at your place of employment? Yes No
Do you have vision insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
Is dental insurance available at your place of employment? Yes No
Do you dental health insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
I058-02-2018 Page 4 of 5 Barcode
If insurance is not available through your employer, is it available through other groups or organizations or your
union?
Yes No
If yes, what group?
Please provide the following information if you are providing insurance or if insurance coverage is offered through your
employer or another group or organization (the costs for each option must be provided to receive credit for the cost of
providing coverage):
Cost of health insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
Cost of vision insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
Cost of dental insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
SECTION D: DEPENDENT CARE EXPENSES
Please provide proof of dependent care expenses. A statement or multiple receipts from the child care provider must be
provided in order to receive credit.
List only child care information necessary due to your employment (for children on this case only):
Child Care Provider
Phone Number
Amount paid
Frequency
Does the Department of Social Services pay any portion of your child care expenses? Yes No
If yes, amount paid:
$
per
SECTION E: PROPERTY AND RESOURCES
Do you own in whole or part any of the following?
Real Estate (Land or Buildings):
Yes No
Fair Market
Price
Location
Amount
Owed
Mortgagee
Income
Producing
Profit per
Year
Yes No
Yes No
Yes No
Other assets:
Yes No
If yes, please explain:
Bank accounts:
Yes No
Name of bank or credit
union:
I058-02-2018 Page 5 of 5 Barcode
I hereby certify under penalty of perjury as set forth in Va. Code § 63.2-502 that I have given the statements in this
document and they are true and correct. I further agree to notify the Division of Child Support Enforcement of any
changes in my income or expenses.
Signature
Date
According to Va. Code § 63.2-1919, financial statements from noncustodial and custodial parents must be filed with the
Department of Social Services upon request as long as a debt to the Department exists or an authorization for the
Department to collect or enforce a support obligation exists. Failure to return this financial statement may adversely
affect your child support obligation and shall constitute a Class 4 misdemeanor.
To obtain additional case and/or payment information, visit our customer service portal at
https://mychildsupport.dss.virginia.gov/.
NOTICE: Section 7 of the Privacy Act (5 USC § 552a) and Section 466(a)(13) of the Social Security Act [42 USC§ 666(a)(13)] require all individuals subject to child
support orders to provide their social security numbers. These numbers will be kept in the case records and will only be used to locate individuals for purposes of
establishing paternity and establishing, modifying, and enforcing support obligations.
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
DIVISION OF CHILD SUPPORT ENFORCEMENT
Health Insurance Verification Notice
Page 1 of 2
DCSEP- 886 12/14
Date: ______________
Dear ______________________, DCSE Case# ______________
This form must be returned to DCSE within 5 days. Failure to return the form along with requested
documentation may result in case closure for non-cooperation, as DCSE will be unable to complete the
guidelines to establish the order.
Under the Affordable Care Act (ACA), the person who claims the child as a tax deduction is responsible for
providing health insurance for the child. Please check if any of the following apply to your situation:
__ The non-custodial parent claims the child(ren) as a tax deduction.
Attach a court order which orders the non-custodial parent to claim the child(ren).
__ The non-custodial parent currently has insurance for the child(ren).
Attach proof of insurance.
__ The child(ren) is(are) currently covered by Medicaid.
Attach proof of insurance.
__ The child(ren) is(are) currently covered by FAMIS.
Attach proof of insurance.
__ The child(ren) is(are) currently covered by my insurance or my spouses insurance.
Attach proof of insurance and proof of the cost of insurance for only the child(ren).
If you did NOT select any of the above, then you must pursue insurance for the child(ren) and select an
option below. You may find subsidized options available at www.healthcare.gov.
__ I will obtain insurance, which may include Medicaid/FAMIS, for the child(ren) prior to my appointment
with DCSE, my court hearing, or returning my financial statement as requested.
Provide proof of insurance and proof of the cost of insurance for only the child(ren) when you come
to your appointment, your court hearing or return your financial statement as requested.
__ Open enrollment periods at my employer and www.healthcare.gov prevent me from enrolling the
child(ren) in insurance prior to my appointment with DCSE, my court hearing, or returning my financial
statement as requested.
Provide proof of open enrollment periods and proof of the cost of insurance for only the child(ren)
when you come to your appointment, your court hearing or return your financial statement as
requested.
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
DIVISION OF CHILD SUPPORT ENFORCEMENT
Health Insurance Verification Notice
Page 2 of 2
DCSEP- 886 12/14
__ The child(ren) does(do) not qualify for Medicaid/FAMIS and the cost of insurance through both my
employer and www.healthcare.gov for only the child(ren) is more than 5% of the combined monthly
gross income of both parents.
Provide proof of the cost of insurance through both your employer and through www.healthcare.gov.
Once you have obtained insurance, the cost of the insurance for only the child(ren) will be shared between
you and the non-custodial parent based upon your shares of your combined monthly gross income.
Thank you for your cooperation.
Sincerely,
____________________________________________
Authorized Representative
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Request for Review and Adjustment Online Forms Instructions (Virginia Department of Motor Vehicles)

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Completed 23 February 2022

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