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

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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#:
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