Please Reply To: Alaska Department of Revenue CSSD, MS Child Support Services Division 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www. childsupport.alaska.gov Mailstop 6 Child Support Services Division 550 W 7th Ave, Suite 310 Anchorage, AK 99501-6699 Request for Administrative Review of Controlling Order Determination (AS 25.25.207) I am requesting an administrative review of the Order Determining Controlling Order issued by CSSD caseworker ________________________ on (date of order) _________________________________. I object to the Order Determining Controlling Order for the following reason(s): ____________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The following documents are attached in support of my objection:________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I understand that the other party may also request a review and may submit documentation. CSSD will conduct the administrative review by reviewing the documentation submitted, by requesting additional information from the parties if necessary, and by obtaining copies of orders or other documentation from other tribunals as needed. CSSD will issue a written decision, which may be appealed to the Alaska superior court. Name Address ___________________________ ___________________________ ___________________________ ___________________________ I am the custodial parent the noncustodial parent Signature _________________________________ CSSD Case Number ___________________ Home Phone _________________________ Work Phone _________________________ from (state/agency) _______________ Date _____________________ Printed Name ______________________________ Complete this request and send it with your supporting documentation to CSSD. CSSD must receive it no later than 30 days from the date of the Order Determining Controlling Order. DO NOT SEND ORIGINALS. They will not be returned or maintained by CSSD. CSSD 04-1919J (New 02/10/05) MAT-SU: (907) 357-3550 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 SOUTHEAST: (907) 465-5887 ANCHORAGE: (907) 269-6900 FAX: (907) 269-6813 or 6914 FAIRBANKS: (907) 451-2830 TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 American LegalNet, Inc. www.USCourtForms.com