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Telephone: ________
Email: ________
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RE: Request for Administrative Review and Modification of Child Support Order
Case/Docket No.: ________
Court/Agency of Jurisdiction: ________
State: ________
Obligor (Paying Parent): ________
Obligee (Receiving Parent): ________
To Whom It May Concern:
§ 1. Purpose of Request. Pursuant to applicable state law and the federal periodic-review provisions of Title IV-D of the Social Security Act (42 U.S.C. § 666(a)(10)) and 45 C.F.R. § 303.8, I respectfully request a review and, if warranted, a modification of my existing child support obligation entered in the above-referenced matter for my minor child, ________, born ________.
§ 2. Current Order. Under the current order, I am obligated to pay to ________ child support in the amount of $________ (________) per month.
§ 3. Origin of the Obligation. This support obligation was established by a divorce decree/order entered on ________ by the court identified above.
§ 4. Basis for Review. I request this review for the following reason(s): (a) a substantial period of time has elapsed since the order was last reviewed, the most recent review having occurred on or about ________; and (b) there has been a substantial and continuing change in circumstances, as more particularly described below:
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§ 5. Supporting Documentation. In support of this request, and consistent with the financial-disclosure requirements applicable to support proceedings, I enclose the following supporting documentation:
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§ 6. Contact Information for Obligor. Should you require any additional information or documentation from me, or wish to schedule a conference or hearing, please contact me at the address set forth above or by the following means:
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§ 7. Contact Information for Obligee. The other parent, ________, may be contacted at the following address:
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§ 9. Verification. I declare under penalty of perjury under the laws of the State of ________ that the foregoing is true and correct to the best of my knowledge and belief.
Sincerely,
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Dated: ________
Enclosures: ________
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