Hamilton County CSEA

Telephone Number: 513-946-7387

222 E. Central Parkway

Toll Free Number: 1-800-315-7119

Cincinnati, OH 45202

Fax Number: 513-946-2396

<Requester's first and last name>

<Requestor Address 1>
<Requestor City, State, Zip>

Case Number:
Order Number:

<SETS number>
<order number>

Date: <print date>

Child Support Obligor: <Obligor's name>
Child Support Obligee: <Obligee's name>

Request for an Administrative Review

of the Child Support Order
I request an administrative review and adjustment of my child support order, including the medical support provisions and any
arrears payments, as set forth in Ohio Administrative Code (OAC) rules 5101:12-60-05 to 5101:12-60-05.6 for the following
reason (please check the appropriate box):
It has been at least 36 months since the date of the most recent child support order.
It has been less than 36 months ago since the date of the most recent child support order. I have marked the appropriate
circumstance which has changed. I have attached any required evidence of the change in circumstance to this form. [If the
required document is not submitted to the Child Support Enforcement Agency (CSEA) with this request, your
request will be denied.]
1.

The existing order established a minimum or a reduced amount of support based on the Child Support
Guidelines due to the unemployment or underemployment of the obligor and the obligor is no longer
unemployed or underemployed. The requesting party must provide to the CSEA relevant evidence or
information supporting an allegation of the change in the obligor's employment status.

2.

I am
The other party is unemployed or laid off, the unemployment or lay off is beyond the partys
control, and the unemployment or lay off has continued uninterrupted for thirty consecutive days. The party
requesting the administrative review must provide to the CSEA relevant evidence of the unemployment or
layoff, including that the unemployment or lay off is beyond the partys control. If the amount of the existing
support order was calculated based on the annualized income of an individual who is employed in a seasonal
occupation, and the cause of the request for a review is a seasonal lay off, then the party does not meet the
criteria for an administrative review under this section.

3.

I am
The other party is unemployed due to a plant closing or mass layoff as defined in the Worker
Adjustment and Retraining Notification (WARN) Act, 29 U.S.C. 2101 et seq. The administrative review
request may only be made after the workers last day of employment. The worker must provide to the CSEA a
copy of the notice of the plant closing or mass layoff provided pursuant to the WARN Act.

4.

I am
The other party is permanently disabled reducing his or her earning ability. The requestor must
provide to the CSEA verification of receipt of benefits administered by the Social Security Administration due
to the disability and/or a physician's complete diagnosis and permanent disability determination.

JFS 01849 (Rev. 2/2009)

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5.

I am
The other party is institutionalized or incarcerated and cannot pay support for the duration of the
child's minority and no income or assets are available to the party which could be levied or attached for
support. The requestor must provide evidence of the institutionalization or incarceration and the inability to
pay support during the child's minority.

JFS 01849 (Rev. 2/2009)

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6.

I have
The other party has experienced a thirty percent decrease, which is beyond the party's control, or
a thirty per cent increase in gross income or income-producing assets for a period of at least six months and
which can reasonably be expected to continue for an extended period of time. The party requesting the
administrative review must provide to the CSEA relevant evidence or information supporting an allegation of a
change in status.

7.

The child support order is not in compliance with the Ohio Child Support Guidelines due to the termination of
the support obligation for a child of the existing support order.

8.

I have children by the same parent in two or more administrative child support orders and I want to combine
the orders into a single administrative child support order.

9.

I want to access available or improved private health insurance coverage that is available for the child. The
requesting party must provide to the CSEA relevant evidence or information supporting the allegation that
access to new or improved private health insurance is available.

10.

I have
The other party has experienced an increase or decrease in the cost of ordered private health
insurance coverage or child care for the child which is expected to result in a change of more than ten percent
to the child support obligation based on the current Child Support Guidelines calculation. The requesting party
must provide to the CSEA relevant evidence or information supporting an allegation of an increase or decrease
in the cost of private health insurance or child care. If the request is based on a change in the cost of private
health insurance, the requesting party must provide to the CSEA evidence regarding the cost of a family plan
and the cost of an individual plan.

11.

The private health insurance that is currently being provided in accordance with the child support order is no
longer reasonable in cost and/or accessible. The requesting party must provide to the CSEA relevant evidence or
information supporting an allegation that the private health insurance is no longer reasonable in cost and/or
accessible.

12.

I am the obligor and I assert that my annual gross income is now below 150% of the federal poverty level and I
should not be ordered to pay cash medical support (the federal poverty guidelines can be found at
http://www.aspe.hhs.gov/povertyor by contacting the CSEA). The obligor must provide to the CSEA relevant
evidence or information supporting an allegation that his or her annual gross income is below 150% of the
federal poverty level.

13.

I am the obligor and I am a member of the uniformed services who has been called to active service for a period
of more than thirty (30) days.
If I have checked this box, I have attached a military Power of Attorney to
permit a designated person to act on my behalf in the administrative review.

14.

A temporary adjustment order pursuant to OAC rule 5101:12-60-05.2 was issued, the obligors term of active
military service has ended, and the obligor has provided the CSEA written documentation sufficient to establish
that the obligor's employer has violated the Uniformed Services Employment and Reemployment Rights Act,
38 U.S.C. 4301 to 4333.

Ohio law requires that a local CSEA provide child support enforcement services on all child support cases, including the review
and adjustment of a child support order. However, a "IV-D case" is eligible for additional services that are not available to a
"non-IV-D case." If you have a "non-IV-D case," you may contact the CSEA for information about completing a IV-D application.
Within 15 days of receiving your request for an administrative review and adjustment and any required evidence, the CSEA will
review your request and determine whether a review should be conducted. Both parties to the order will be notified of the date
and location of the administrative review. The notice will be mailed to the last known address of both parties. The notification will
also request that you provide financial information, medical support information, and any other information necessary to properly
review the child support order. If your request is denied, the CSEA will send you notice of the denial.
Please be aware that you may not dismiss your request for an administrative review on or after the scheduled review date.
Also, requesting an administrative review may result in the monthly support obligation increasing, decreasing, or
remaining the same or in a change in the medical support provisions.
PLEASE LIST ALL DOCUMENTS THAT YOU ATTACHED:

JFS 01849 (Rev. 2/2009)

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_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Signature of Requestor

Printed Name of Requestor

Please provide your current address if different from page 1:
Address:

_____________________________________
Date
_____________________________________
_____________________________________
Daytime Telephone Number

JFS 01849 (Rev. 2/2009)

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