I understand and assume full responsibility for the accuracy of the information that I have provided in this request. I understand that the Review and Modification Unit will use this information to determine whether a review and possible modification of the support order is appropriate and that this decision will be based on criteria established by the Review and Modification Unit for the review and modification process.

I understand a review and referral for possible modification of the child support order will not suspend any enforcement activity if the party who is ordered to pay support is delinquent in their payments.

I understand that the review and modification process is limited to only those issues directly related to child and/or medical support and does not address issues such as custody or visitation or spousal support.

I understand that I am requesting a review to determine whether the present support amount is consistent with the amount of support under the Nebraska Child Support Guidelines.

I understand that I am required to provide proof of my income and a copy of my most recent support order. I further understand that this information will be used to determine the amount of support that should be paid based on the guidelines. The required documentation includes copies of:

1. Last two years federal income tax returns with all IRS schedules;
2. All W-2's for the last two years;
3. All IRS Form 1099's for the last two years;
4. Pay stubs for the last three months or a written statement of my income from my employer;
5. Verification of all income not included in #4; and
6. Copy of the original court order, all modifications and guideline calculations, including the Property Settlement Agreement if applicable.

I understand that if all required documents are not provided, the request will not be processed.

I understand that I am responsible for providing any additional information that may be requested by the Review and Modification Unit for the purposes of completing the review and modification process.

I understand that the Review and Modification Unit has access to the records of various state and federal agencies that may be used to confirm the financial information I provide.

I understand the Review and Modification Unit will review the possibility of including health care coverage in the support order if it is not currently included even if the dollar amount of the child support is not adjusted.

I understand that the Review and Modification Unit does not have the authority to modify a support order entered by the courts, but may refer the case to the county/authorized attorney to file an application for possible modification.

I understand that a decision by the Review and Modification Unit not to refer the order for possible modification does not affect my right to petition the courts directly for modification.

I understand that the county/authorized attorney employed by or under contract with the Department of Health and Human Services is not my legal representative, that an attorney-client relationship does not exist between the attorney and myself and, therefore, there is no privilege of confidentiality to myself that would have otherwise existed as a result of an attorney-client relationship. The county/authorized attorney is working solely for the state or county, pursuant to Nebraska Revised Statutes, Sections §43-512.03 et seq. (Reissue of 1988) and will not handle custody or visitation issues.

I understand that I have the right to obtain legal services of a private attorney at my own cost to represent me, if any action is taken to modify the current support order. I further understand that I must inform the Review and Modification Unit and/or the county/authorized attorney if I do so.

I understand that if the support order is modified to change the amount of support or to include health care coverage, the county/authorized attorney will establish income withholding against the party required to pay support pursuant to Nebraska Revised Statutes, §§ 43-1701 to 43-1743.

I understand that after a review determination is made and I have been notified of the results by the Review and Modification Unit, I cannot withdraw my request.

Please note that if the court does order health care coverage, the cost may be considered in the child support calculation which may reduce the amount of child support ordered.

Privacy Act of 1974 Notice: Disclosure of your social security number, and the social security numbers of your children, is required by federal law 42 U.S.C. 666 (a) (13). Child Support Enforcement will use these social security numbers only for the purpose of establishing and enforcing support.

I have read and understand the conditions of this request and want the child support order reviewed. I am agreeing to terms of this Statement of Understanding by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on an application.