Request for Modification, Termination or Credit on Arrears - Change ...

STATE OF OREGON, Child Supp<strong>or</strong>t Program (CSP), by the Administrat<strong>or</strong> (ORS 25.010)County: Court #: CSP #:[ ] Other Jurisdiction: Case #:Children:Oblig<strong>or</strong>:Obligee:[ ] Other parties:Change of Custody<strong>Request</strong> <strong>f<strong>or</strong></strong> <strong>Modification</strong>, <strong>Termination</strong> <strong>or</strong> <strong>Credit</strong> on ArrearsBy signing this <strong>f<strong>or</strong></strong>m, I request the Child Supp<strong>or</strong>t Program (CSP) review my supp<strong>or</strong>t <strong>or</strong>der based on achange of custody.I know this request may change the <strong>or</strong>der because the CSP will apply the current child supp<strong>or</strong>tguidelines to my present circumstances. This may result in either parent being required to pay cashchild supp<strong>or</strong>t, pay cash medical supp<strong>or</strong>t and provide health care coverage. [OAR 137-050-0700 to 137-050-0765]Since the <strong>or</strong>der was entered <strong>or</strong> last reviewed, custody has changed as follows:Check all that apply: I don’t want child supp<strong>or</strong>t from the other party. By choosing this option, I know the CSP won’tmodify the <strong>or</strong>der to have the other party pay supp<strong>or</strong>t <strong>f<strong>or</strong></strong> at least 35 months unless there is asubstantial change of circumstances.I want child supp<strong>or</strong>t from the other party. This request is my application <strong>f<strong>or</strong></strong> child supp<strong>or</strong>tservices.I want a credit against my arrears. I am asking <strong>f<strong>or</strong></strong> the credit because all the min<strong>or</strong> children havebeen living with me since . [OAR 137-055-5510]Complete and return the enclosed Uni<strong>f<strong>or</strong></strong>m Income and Expense Statement (UIES) with thisrequest. Send any additional in<strong>f<strong>or</strong></strong>mation <strong>or</strong> proof of the custody change with this request.If you have an att<strong>or</strong>ney <strong>f<strong>or</strong></strong> child supp<strong>or</strong>t issues, give us their name, address, and phone number:Page 1 of 2 - CHANGE OF CUSTODY REQUEST FOR MODIFICATION, TERMINATION OR CREDIT ON ARREARSCSF 01 0142C (Rev. 01/26/12) CSCM Initials CSP#:

If my request results in a legal action, I understand that legal documents will be sent to me byregular mail at the address below.Date Signature Printed NameAddress City State ZipThe address you list above will be your "contact address.” We will use it to send documents to you. It will also appear inlegal papers given to the other parent and in court rec<strong>or</strong>ds. If you do not want your residence <strong>or</strong> mailing address to begiven to the other party <strong>or</strong> appear in court rec<strong>or</strong>ds, you must give us a different address in your state <strong>f<strong>or</strong></strong> the CSP to use asyour "contact address." If the address you give now is different than one you gave us be<strong>f<strong>or</strong></strong>e, we will use the new one fromnow on.Division of Child Supp<strong>or</strong>t`` ` `Telephone: `Fax: `TTY: (800) 735-2900The Child Supp<strong>or</strong>t Program can provide you with in<strong>f<strong>or</strong></strong>mation from <strong>f<strong>or</strong></strong>ms and other notices inyour own language free of charge. This also includes Braille, large print, and the use of interpreters. Tofind out m<strong>or</strong>e, contact your child supp<strong>or</strong>t office.The Child Supp<strong>or</strong>t Program (CSP) provides services <strong>f<strong>or</strong></strong> the State of Oregon. We cannotrepresent you <strong>or</strong> give you legal advice. You may contact your own lawyer at any time. Low cost legalservices may be available. F<strong>or</strong> in<strong>f<strong>or</strong></strong>mation, you may visit the CSP website at <strong>or</strong>egonchildsupp<strong>or</strong>t.gov.Page 2 of 2 - CHANGE OF CUSTODY REQUEST FOR MODIFICATION, TERMINATION OR CREDIT ON ARREARSCSF 01 0142C (Rev. 01/26/12) CSCM Initials CSP#:

STATE OF OREGON, Child Supp<strong>or</strong>t Program (CSP), by the Administrat<strong>or</strong> (ORS 25.010)County: Court #: CSP #:[ ] Other Jurisdiction: Case #:Children:Oblig<strong>or</strong>:Obligee:[ ] Other parties:Uni<strong>f<strong>or</strong></strong>m Income & Expense StatementContact in<strong>f<strong>or</strong></strong>mation:Cell #: Text? Yes No Message #:Home #:Email:Date Signature Printed NameAddress City State ZipThe address you list above will be your “contact address.” We will use it to send documents to you. It will also appear in legalpapers given to the other parent and in court rec<strong>or</strong>ds. If you do not want your residence <strong>or</strong> mailing address to be given to theother party <strong>or</strong> appear in court rec<strong>or</strong>ds, you must give us a different address in your state <strong>f<strong>or</strong></strong> the CSP to use as your “contactaddress.” If the address you give now is different than one you gave us be<strong>f<strong>or</strong></strong>e, we will use the new one from now on.List all ‘Joint Children’ in this Order (children under the age of 21, b<strong>or</strong>n to <strong>or</strong> adopted by the parties)Name of Child DateChildren Living With:Child 18-20 in If Child 18, inofSchool High SchoolBirthOtherYes No Yes NoMe Parent Other (Name)List your additional joint children on a separate sheet of paper.Do you already have a supp<strong>or</strong>t <strong>or</strong>der <strong>f<strong>or</strong></strong> these children? Yes No If yes, explain and attach themost recent copy of your <strong>or</strong>ders, if available:Do you have a parenting time <strong>or</strong>der <strong>or</strong> written parenting time agreement <strong>f<strong>or</strong></strong> these children? Yes No If yes, attach a copy of the <strong>or</strong>der <strong>or</strong> agreement.Page 1 of 4 - UNIFORM INCOME & EXPENSE STATEMENTCSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

Do you supp<strong>or</strong>t other children in your home <strong>or</strong> have a supp<strong>or</strong>t <strong>or</strong>der <strong>f<strong>or</strong></strong> children not in your home? Yes No If yes, list them below.Child’s First NameDate ofBirthRelationship(daughter,son, etc.)If there is an <strong>or</strong>der <strong>f<strong>or</strong></strong> you topay supp<strong>or</strong>t, provide state,county & court number.Child 18 inHigh Schoolin Your HomeYes NoList biological and adopted children <strong>or</strong> stepchildren you are <strong>or</strong>dered to supp<strong>or</strong>t. List other children you supp<strong>or</strong>t on a separate piece of paper.Do you pay <strong>or</strong> receive spousal supp<strong>or</strong>t? Yes NoAmount paid: $to whomAmount received: $from whomAre you employed? Yes NoName, address, & phone number of employer:How many hours per week do you w<strong>or</strong>k?Do you consistently receive wages <strong>f<strong>or</strong></strong> overtimehours? Yes NoWhat is your monthly income be<strong>f<strong>or</strong></strong>e deductions? $. Attach a copy of your most recentpay stub.Do you pay mandat<strong>or</strong>y union dues? Yes No If yes, how much per month? $Do you receive expense reimbursements <strong>or</strong> allowances <strong>f<strong>or</strong></strong> a car, cell phone, housing, subsidies, <strong>or</strong> anyother expenses which reduce your living expenses? Yes No If yes, how much per month? $Attach proof you receive expense reimbursements <strong>or</strong> allowances.Are you unemployed? Yes NoAre you receiving w<strong>or</strong>kers' compensation <strong>or</strong> unemployment benefits? Yes NoIf yes, list the source and the amount of the monthly <strong>or</strong> weekly benefit:Source: Amount: $ Monthly WeeklyWhat type of w<strong>or</strong>k have you done in the last five years?Why did your last job end?Are you self-employed? Yes NoName, address, & phone number of your business:Attach a copy of your most recent tax return (personal and business, including all schedules) <strong>or</strong>profit & loss statement.Page 2 of 4 - UNIFORM INCOME & EXPENSE STATEMENTCSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

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, disabilityinsurance benefits, prizes, lottery, alimony, Supplemental Security income, and distributions from a trust.Income does not include child supp<strong>or</strong>t, food stamp benefits, Social Security resulting from a child’sdisability, adoption assistance, guardianship assistance, and foster care subsidies.Source: Amount: $Source: Amount: $Do you have child care costs <strong>f<strong>or</strong></strong> the ‘Joint’ children? Yes NoAre the children 12 years old <strong>or</strong> under? Yes No Are the children disabled? Yes NoIf you answered yes to either question, list the name(s) of the children, date(s) of birth and amount(s)you pay <strong>f<strong>or</strong></strong> their care and attach proof of child care costs: (Only include the costs you pay out ofpocket.)Amount: $Amount: $Amount: $Amount: $Are you paying <strong>f<strong>or</strong></strong> your own health care coverage? Yes No If yes, what is your monthly cost?$ . Attach proof of coverage showing your monthly cost.Is health care coverage available <strong>f<strong>or</strong></strong> your children? Yes No If yes, who insures the children?Source of insurance: employer other group spouse domestic partner otherInsurance Co.: Phone #:AddressPolicy #: Group #: Effective date of the policy:Monthly cost per child $ Name(s) of children currently covered by insurance:Do you pay ongoing medical expenses <strong>f<strong>or</strong></strong> the children? Yes NoIf yes, list the name(s) of children, the reason <strong>f<strong>or</strong></strong> the expense, and the monthly cost:Amount: $Amount: $Attach proof of insurance and ongoing medical expenses <strong>f<strong>or</strong></strong> the children.Do any of your children receive Social Security <strong>or</strong> Veteran’s benefits due to a parent=s disability <strong>or</strong>retirement? Yes NoWhat type of benefit do they receive? Surviv<strong>or</strong>s and Dependents Educational Assistance Social Security benefits App<strong>or</strong>tioned Veteran’s benefits due to the disability <strong>or</strong> retirement of a parentWhat is the total monthly benefit amount the children receive? $If your child is in state care, do you have regular visits? Yes NoIf so, how far do you travel?How often do you visit?Does the Department of Human Services pay any of these expenses? Yes NoPage 3 of 4 - UNIFORM INCOME & EXPENSE STATEMENTCSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#: