LICKING COUNTY CHILD SUPPORT ENFORCEMENT AGENCY Craig R. Baldw in, Director 65 East Main Street ® P.O. Box 338 ® Newark, OH 43058-0338 COMMISSIONERS Albert Ashbrook Marcia Phelps Jay Baird Telephone 740-349-6575 800-513-1128 Fax 740-349-6582 Upon receipt of the Request for Child Support Review the CSEA will determine if, according to Ohio Law and the Ohio Department of Human Services Rules, a review should be conducted. You will be notified of this decision within 15 working days of receipt of your request by the CSEA. The review will be conducted by the CSEA in 45 days. The modified amount of child support will be effective on the first day of the month following the Review. Both parties will be required to supply the CSEA with pertinent information and verification of the same in order to apply the Ohio Child Support Guidelines. Please keep in mind that we will be looking at the parties= current circumstances. Your = order for support may increase, decrease, or it may remain the same. If the agency determines a review of the child support is not warranted at this time, you will have 90 days to request state administrative remedy. Complete the enclosed application and return it to the CSEA. The review process will not begin until the application is received. a Our mission is to provide child support services with knowledge, dedication and professionalism. b Visit us on the web at www.ohio.gov/odjfs/county/licking/ E-mail us at LCCSEA@odjfs.state.oh.us American LegalNet, Inc. www.USCourtForms.com REQUEST FOR CSEA REVIEW OF CHILD SUPPORT ORDER ABOUT YOU . . . Personal Information: Name Address Phone: Home Work Social Security Number Date of Birth Court Case Number Employment Information: Employer Name Address Income Information: Earned Income - Previous Year Current Other (Please Explain) ABOUT THE OTHER PARTY . . . Name Address Phone: Home Social Security Number Work Date of Birth Employer Name Address American LegalNet, Inc. www.USCourtForms.com CIRCUMSTANCES WHICH WARRANT A REVIEW: If your order was established within the past 36 months, you are required to indicate which circumstance applies to your situation! A minimum amount of support was ordered at the time of the last order (due to unemployment or underemployment) and the obligor is now gainfully employed. The obligor has experienced a loss or reduction of employment for a period of at least six months, WHICH IS BEYOND HIS/HER CONTROL, and which can reasonably be expected to continue for an extended period of time. (You must provide proof of reason of termination of employment with this application.) The obligor has become permanently disabled reducing his or her earning ability. (The disability shall be medically verified by the receipt of social security disability and/or a physician's complete diagnosis and determination.) Either parent has had a 30% change in gross income (since the last review of support) not related to the first three items. (You must provide proof of change of income.) Which party has the 30% change in income ___ you or ___ other party? Reason for change in income (ie, terminated, laid-off etc) One of the children of the order has been deleted from the order due to emancipation or otherwise. There has been a change in the availability of health insurance. Which party is ordered to carry insurance ___ you or ___ other party? (You must provide proof of change in availability.) The current child support ordered is a deviation from the changed guideline amount and the deviation factor has changed. What is the changes in the deviation factor? IF NONE OF THE ABOVE APPLY, PLEASE ATTACH AN EXPLANATION OF YOUR REASON FOR REQUESTING A MODIFICATION REVIEW. READ THE FOLLOWING STATEMENTS. I understand that in requesting this review of my child support order, the CSEA is required to perform the review based upon Ohio Revised Code '3113.215, the Child Support Guidelines. I understand that in order for the review to be performed, I will be required to provide further information and verification to the CSEA within 30 days of receipt of the approval of my request. I understand that by performing this review, the Child Support Enforcement Agency does not represent me or the other party in the action, but rather represents the State of Ohio. Your signature indicates that you have read the above statements, that you understand the above statements and that you are in agreement with the above statements. Your Signature Date American LegalNet, Inc. www.USCourtForms.com