Form 3L015Ae – Fill Out and Use This PDF

A T T O R N E Y G E N E R A L O F T E X A S

G R E G A B B O T T

C H I L D S U P P O R T D I V I S I O N

Dear Parent:

Re: Your Request for Review

Thank you for your inquiry regarding a review of your child support order. Please sign this form and return it with the completed Child Support Review Questionnaire to the child support office that is handling your case. You can find the address by calling (800)252-8014, or selecting “ Child Support Interactive” from the child support section of the Attorney General’s Web site at www.texasattorneygeneral.gov.

I request the Child Support Division of the Office of the Attorney General to conduct a review of my child support order. I understand the following:

•The attorneys of the Office of the Attorney General represent the State of Texas. They will provide me with child support services, but do not represent me or any other individual.

•A review addresses only child support and medical support.

•The non-custodial parent may be required to provide medical insurance for the child(ren).

•A review of a child support order will determine if the order complies with the Texas child support guidelines.

•A request for a review may be withdrawn by the requestor.

Please list the reason you are requesting a review:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

____________________________	____________________________
Signature	Date Signed

Within three weeks of receiving all of the necessary information from you, we will determine if a review of your child support order is appropriate and we will notify you of our decision. If it is determined that a review should be conducted, the other party named in your child support order will be asked to complete a questionnaire. Thank you for your cooperation.

Office of the Attorney General

Child Support Division

O c t o b e r 2 0 0 9

A n E q u a l E m p l o y m e n t O p p o r t u ni t y E m p l o y e r " P r i n t e d o n R e c y c l e d P a p e r

Form 3L015ae- online

GREG ABBOTT

Attorney General

CHILD SUPPORT REVIEW QUESTIONNAIRE

INSTRUCTIONS

Please type, print, or write clearly. Answer all questions as completely and accurately as you can. Please return the completed form along with copies of your:

• income tax returns for the past two years

• two most recent payroll stubs

If you do not have these items, please send us your W-2 Forms for the past two years.

INFORMATION ABOUT YOU (Please Print All Information)

Name (Last, First, Middle)		Social Security No .			Da te of Birth		Relationship to Child(ren)
Address: Street Address	Apt . #			City		State		ZIP Code
Home Telephone No .	Work Telephone No .
			Do you have custody of the child(ren)? ‘ YES					‘ NO
Employer						Employer’s Telephone No .
Employer’s Address: Street Address				City			State	ZIP Code

INFORMATION ABOUT THE OTHER PARTY

INFORMATION ABOUT THE CHILD(REN) (List only your children with the other party named above.)

September 2005

Page 1

Form 3F002e

FINANCIAL INFORMATION

					CURRENT INFORMATION		INFORMATION AT TIME OF
							LAST SUPPORT ORDER
YOUR GROSS (before any deductions) MONTHLY INCOME FROM:					AMOUNT		AMOUNT
Salary and Wages (including commissions, bonuses, and overtime)
Self-Employment
Pensions and Retirement
Social Security Benefits
Unemployment Benefits
Disability and Workers’ Compensation Benefits
Dividends and Interest
Net Rentals
Other (specify):
	TOTAL MONTHLY INCOME
					CURRENT INFORMATION		INFORMATION AT TIME OF
							LAST SUPPORT ORDER
YOUR MONTHLY DEDUCTIONS FOR:					AMOUNT		AMOUNT
Union Dues
Health Insurance You Pay For Your Child(ren) On This Order
Insurance Company	Policy Number		Child(ren) Covered
	TOTAL MONTHLY DEDUCTIONS
					CURRENT INFORMATION		INFORMATION AT TIME OF
							LAST SUPPORT ORDER
YOUR ASSETS:					AMOUNT		AMOUNT
Cash On Hand
Money in Checking Accounts
Money in Savings Accounts
Money in Any Other Accounts
Retirement or Pension Funds
Life Insurance Cash Value
Stocks, Bonds, or Other Investment Securities
Real Estate
Other Assets (please specify)
	TOTAL VALUE OF ALL ASSETS
					CURRENT INFORMATION		INFORMATION AT TIME OF
							LAST SUPPORT ORDER
CHILDREN:					NUMBER		NUMBER
Children you are legally obligated to support either in you home or by court order.

September 2005

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Form 3F002e

Read the statements below. Check the box next to those you believe are true, and explain why.

‘ The other parent’s income has substantially (check one) ‘ increased ‘ decreased since the date of the current child support order.

By how much? $			per
Explain why

Do you have any other children, not already mentioned in this questionnaire, who currently live with you?

‘ Yes ‘ No If “yes”, complete the box below. Do not include stepchildren.

Do you have any other children, not already mentioned in this questionnaire, whom you are legally obligated to support?

‘ Yes

‘ No

If “yes”, complete the box below. Please attach copies of your court orders, if available.

Is there any other information we should consider that has not been covered in this questionnaire? For example; Special needs of the children subject to this order.

Explain

By my signature below, I certify that the information provided by me in this form is true and correct to the best of my knowledge.

Texas Government Code § 559 gives you the right to review and request correction of information on this form.

Signature

Date Signed

September 2005

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Form 3F002e