Request For Review And Adjustment Online Forms

1686178501
ADVERTISEMENT
Request for review and adjustment online forms

File Name: R&A_Online_Packet.pdf

File Size: 369.51 KB

File Type: Application/pdf

Last Modified: 11 months

Status: Available

Last checked: 2 hours ago!

This Document Has Been Certified by a Professional

100% customizable

Language: English

We recommend downloading this file onto your computer

Summary

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 [email protected]

• A review and adjustment specialist will contact you to confirm receipt of
your documents and gather any further needed information

Commonwealth of Virginia PO Box 550
Department of Social Services Richmond, VA 23218
Division of Child Support Enforcement http://www.dss.virginia.gov/family/dcse/
1-800-468-8894
REQUEST FOR REVIEW AND ADJUSTMENT
Name ___________________________________ Date _________________________________________
Address ___________________________________ Division Case Number ___________________________
___________________________________
___________________________________
Please read this information before submitting the attached request for a review of your child support order

If it has been 3 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 for your request

If it has been less than 3 years since your child support order was entered, modified or reviewed, there must be a special
circumstance to justify the request. The special circumstances and required documents are:
• A child needs to be added to the order due to birth or change in physical custody. Provide child’s name and birth
date

• A child is no longer eligible to receive current support due to a change in physical custody or emancipation (and
other children are active on the order). Provide child’s name and birth date

• Health care coverage cost increases or decreases by at least 25%. Provide a statement from the insurer or employer
that specifies the cost of the child(ren)'s premium to the insured. You may provide current and previous costs of the
child(ren)’s premium in writing on the request, but only if you cannot obtain a statement from the insurer or
employer

• A health care coverage obligation needs to be added to the order. No documentation is necessary

• The order does not include an unreimbursed medical/dental provision. No documentation is necessary

• Either parent's income increases or decreases by at least 25%. 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 and list the
reason for the change of income. If your decrease or loss of income is not voluntary, please provide verification with
this request

• Either parent is a Reservist or National Guard member whose income is changing due to recall to active duty

Provide any document that supports a return to active duty

• The parent who owes child support is incarcerated for 180 or more consecutive days

• Work-related child care expenses increase or decrease by at least 25%. Submit a statement from the child care
provider that specifies the child care cost and the name(s) of the child(ren) in the provider’s care

The Division will conduct a review if a special circumstance applies to the other party and you cannot obtain the
required documentation. However, as the requesting party, you must provide an explanation of the other party's special
circumstance

You must indicate the reason for the request. If your request is based on a change in circumstance, the change must
qualify as one of the special circumstances listed above. Clearly state the special circumstance and provide the required
I033-02-2018 (Rev. 07/2022) Page 1 of 2 Barcode
documentation. The Division will not accept any requests that do not indicate the reason and include the required
documentation

Once the Division receives a request, it may only be withdrawn by written request; however, if the non-requesting party
objects to the withdrawal, action to complete the review will continue

A review could result in an upward or 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 submit this form and the
required documentation to the address above

To obtain additional case and/or payment information, visit our customer service portal at
http://mychildsupport.dss.virginia.gov/

REQUEST FOR REVIEW AND ADJUSTMENT
Division Case Number: ______________________________
I request a review because:
Printed Name Signature
Date: Address:
Cell Phone:
Email Address:
I033-07-2022 (Rev. 07/2022) Page 2 of 2 Barcode
Commonwealth of Virginia
Department of Social Services
Division of Child Support Enforcement
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 ($ amt and pay
(Person you pay) (Over last 6 months)
Administrative) frequency)
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 1 of 5 Barcode
If you pay or receive spousal support/alimony, provide the following information:
$ Paid to/Received
Order Date Issuing Court
Amount/Frequency 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 2nd 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 2 of 5 Barcode
Past employment and periods of unemployment: List all previous employers and periods of unemployment for
the last 12 months:
Gross
Employment
Monthly
Dates
Name Address Income
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 Are the children on this case included in the policy? Yes
No No
Name and relationship of others covered in this policy:
Name Relationship
Name of insurance
Policy number:
company:
Is vision insurance available at your place of employment? Yes No
Do you have vision insurance? Yes Are the children on this case included in the policy? Yes
No No
Name and relationship of others covered in this policy:
Name Relationship
Name of insurance
Policy number:
company:
Is dental insurance available at your place of employment? Yes No
Do you dental health insurance? Yes Are the children on this case included in the policy? Yes
No No
Name and relationship of others covered in this policy:
Name Relationship
Name of insurance
company: Policy number:
I058-02-2018 Page 3 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 Amount Income Profit per
Price Location Owed Mortgagee Producing 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 4 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

I058-02-2018 Page 5 of 5 Barcode
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
DIVISION OF CHILD SUPPORT ENFORCEMENT
Health Insurance Verification Notice
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

Page 1 of 2
DCSEP- 886 12/14
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
DIVISION OF CHILD SUPPORT ENFORCEMENT
Health Insurance Verification Notice
__ 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
Page 2 of 2
DCSEP- 886 12/14

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 …

Download Now

Documemt Updated

ADVERTISEMENT

Popular Download

ADVERTISEMENT

Frequently Asked Questions

How do i request a review and adjustment of child support?

The review and adjustment may be conducted judicially by the court or administratively by the Department of Human Services and/or a local child support office. If you are interested in learning more about the review and adjustment process, you may contact your local child support office.

What information do i need to complete the review and adjustment?

However, you are required to complete all other fields including your name, address, case and order number, date application completed, the reason why you believe you qualify for a review and adjustment, along with your signature and telephone number.

What is administrative review for distribution of child support payments?

Administrative Review - Distribution of Child Support Payments (1 TAC 55.141 (e)) This form is used by a custodial parent, who is a current or former Temporary Assistance for Needy Families (TANF) recipient, to request an Administrative Review hearing to resolve disputed issues concerning distribution of payments. View the form in English

How does the administrative adjustment and review process work?

With the administrative adjustment and review process, a CSEA will consider your case and present a recommendation for a possible adjustment. The amount you pay could go up, go down or stay the same.