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SUPPORT PAYMENT CREDIT INFORMATION SHEET

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If you are seeking credit where money was NOT owed to the State of Oregon, form CSF 01 0321
(Support Payment Credit Agreement (Support Not Assigned)) is enclosed. Complete and return the
form to the office listed on this form.
Both the obligor and obligee or child attending school must sign this form for credit to be given.

2.

If you are seeking credit where money was owed to the State of Oregon, form CSF 01 0322 (Support
Payment Credit Agreement Payments Assigned) is enclosed. Complete and return the form to the office
listed on this form.
Both the obligor and obligee or child attending school must sign this form in front of a notary for credit to
be given.

3.

If you are seeking credit where money was owed to another state, send proof from that state to the
office listed on this form.

4.

If the obligee or child attending school (if applicable) won't agree, or the other state won't give you proof,
you can ask for a hearing. Complete form CSF 01 0323 (Hearing Request for Support Payment Credit)
and return the completed form to the office listed on this form.

RETURN COMPLETED FORM(S) TO:

Division of Child Support
Financial Services Unit
4600 25th Ave NE, Ste 180
Salem, OR 97301
Telephone: (503) 373-7300
TTY: (800) 735-2900

The Child Support Program (CSP) provides services for the State of Oregon. We cannot represent you or give
you legal advice. You may contact your own lawyer at any time. Low cost legal services may be available. For
information you may visit the CSP website at www.doj.state.or.us and choose GET HELP WITH CHILD
SUPPORT.

Page 1 of 1 - SUPPORT PAYMENT CREDIT INFORMATION SHEET

CSF 01 0320 (Rev. 07/02/10)

SUPPORT PAYMENT CREDIT AGREEMENT

(SUPPORT NOT ASSIGNED)
CSP #:
Obligor:
Obligee:
By signing this form, we agree that the following support payments have been paid and should be credited to the
Department of Justice account indicated above.
NOTICE TO PARTIES: The amounts in this credit agreement have not been reviewed for
accuracy by the Child Support Program. It is your responsibility to review the amounts and to make
appropriate revisions before signing the agreement.
If you have questions, you may contact a lawyer or call or visit the enforcing agency.
NOTICE TO OBLIGEE/CHILD ATTENDING SCHOOL: If you were receiving public assistance and
did not report the payments listed below, you may be subject to criminal or civil liability. This form
may be used in a hearing as evidence of receipt of payment.
OBLIGOR TO COMPLETE
Approximate Date

Amount

OBLIGEE/CHILD ATTENDING SCHOOL

TO COMPLETE
Approximate Date
Amount

TOTAL

TOTAL

OBLIGOR

OBLIGEE/CHILD ATTENDING SCHOOL

Signature:

Signature:

Date:

Date:

THIS OFFICE PROVIDES SERVICES ON BEHALF OF THE STATE OF OREGON. WE

CANNOT REPRESENT YOU OR GIVE YOU LEGAL ADVICE. YOU MAY CONTACT YOUR
OWN LAWYER AT ANY TIME.

Page 1 of 1 - SUPPORT PAYMENT CREDIT AGREEMENT (SUPPORT NOT ASSIGNED)

CSF 01 0321 (Rev. 03/03/07)

SUPPORT PAYMENT CREDIT AGREEMENT

(PAYMENTS ASSIGNED)
CSP #:
Obligor:
Obligee:
By signing this form, we agree that the following support payments have been paid and should be credited to the
Department of Justice account indicated above. Canceled checks or other substantial proof of payment is/are attached.
NOTICE TO PARTIES: The amounts in this credit agreement have not been reviewed for
accuracy by the Child Support Program. It is your responsibility to review the amounts and to make
appropriate revisions before signing the agreement.
If you have questions, you may contact a lawyer or call or visit the enforcing agency.
NOTICE TO OBLIGEE/CHILD ATTENDING SCHOOL: If you were receiving public assistance and
did not report the payments listed below, you may be subject to criminal or civil liability. This form
may be used in a hearing as evidence of receipt of payment.
Approximate Date

Amount

Approximate Date

Amount

TOTAL

TOTAL

OBLIGOR

OBLIGEE/CHILD ATTENDING SCHOOL

Signature:
State of
County of

Signature:

Date:
)
)
)

State of
ss.

SUBSCRIBED AND SWORN to before me by

on
,

County of

Date:
)
)
)

ss.

SUBSCRIBED AND SWORN to before me by

on
,

Notary Public for

My commission expires:

Notary Public for

My commission expires:

THIS OFFICE PROVIDES SERVICES ON BEHALF OF THE STATE OF OREGON. WE

CANNOT REPRESENT YOU OR GIVE YOU LEGAL ADVICE. YOU MAY CONTACT YOUR
OWN LAWYER AT ANY TIME.

Page 1 of 1 - SUPPORT PAYMENT CREDIT AGREEMENT (PAYMENTS ASSIGNED)

CSF 01 0322 (Rev. 03/03/07)

HEARING REQUEST FOR SUPPORT PAYMENT CREDIT

ORS 25.020; OAR 137-055-5240

CSP #:
Obligor:
Obligee:
I request a hearing to decide whether my support account should be credited for the following
payments which were not paid to the Department of Justice, but were paid as support payments. I have
not been able to get an agreement or sworn statement from the obligee, child attending school/adult
child
, or proof from another state. Other state:
[ ] I will need an interpreter for the hearing. Language:
Approximate
Date

Approximate
Date

Amount

Amount

TOTAL
TOTAL
Please attach copies of canceled checks or other substantial proof of payment.
Signature

Social Security Number

Print Name Clearly

Mailing or Contact Address

City

State

Date

Phone Number ALJ Should Call

Zip

NOTICE TO PARTIES: The amounts in this hearing request have not been reviewed for
accuracy by the Child Support Program. If you disagree with the amounts, send any proof showing
different payment amounts to the address listed on this form and appear at the time and place of the
hearing to have your objections considered. See ORS 25.020, ORS 107.108, OAR 137-055-5120 and
OAR 137-055-5240.
Page 1 of 3 - HEARING REQUEST FOR SUPPORT PAYMENT CREDIT ORS 25.020; OAR 137-055-5240
CSF 01 0323 (Rev. 10/22/13)

When one party requests a hearing, he or she may later withdraw the request. Even if another party
has already requested a hearing, if you also want a hearing to take place, you must request a hearing
within the time limit stated in the notice or other document you received to ensure that a hearing will be
scheduled.

If this request is submitted for an administrative hearing, the Child Support Program designates
its file in this matter as the record in this case.

If you have any questions, you may contact a lawyer or call or visit the enforcing agency.
YOUR HEARING RIGHTS
1.

Hearings are held by the Office of Administrative Hearings (OAH). The administrative law
judge=s (ALJ) decision may be appealed to the circuit court of the State of Oregon.

2.

This hearing for child support credit will consider only the issue of credit for payment(s) paid but
not to Department of Justice.

3.

The hearing will be held by a telephone conference, using a call-in number or the ALJ calling
you directly. OAH will send you a notice of the time and place of the hearing at your mailing
address. This notice will also have instructions about telephone hearings. Please read and follow
the instructions carefully. Be sure you give us a phone number (on the first page of this form)
where you can be reached for the hearing. If you do not appear for the hearing, your request for
credit may be dismissed and your child support account will not be credited.
** Any call blocking or caller identification feature(s) on your phone MUST be turned off
BEFORE your hearing. **

4.

At the hearing you will have a chance to explain why you believe credit should be given. You
may provide canceled checks or other proof of payment. You can have people testify for you.
You can have a lawyer help you at your own expense.

5.

A copy of this completed form will be sent to the other party(ies) as a part of the hearing notice.
If money is owed to the state, the enforcing agency will also get a copy. The other party(ies) will
have the opportunity to object and be heard at the hearing.

6.

This completed form along with any proof of payment must be sent to the address listed on this
form.
PROTECTING A SERVICEMEMBERS RIGHTS
50 USC App 501-597b

Active duty servicemembers have a right to stay (delay) proceedings under the federal
Servicemembers Civil Relief Act. Servicemembers may contact the Oregon State Bar toll-free inside
Oregon at 800-452-8260 or 503-620-0222 or the Oregon Military Department toll-free at 800-452-7500
for more information. The United States Armed Forces Legal Assistance Legal Services Locator website
may be accessed at legalassistance.law.af.mil.

Page 2 of 3 - HEARING REQUEST FOR SUPPORT PAYMENT CREDIT ORS 25.020; OAR 137-055-5240
CSF 01 0323 (Rev. 10/22/13)

NOTE: The Child Support Program or the courts may show one or both parent=s address on their
documents of record. If you are concerned about having your address shown, please tell the Child
Support Program. By law, you are allowed to give another mailing address at which you will accept
legal papers. This is known as the Acontact address@ and must be in the same state as your home
address.
Division of Child Support
`
```
Telephone: `
FAX: `
TTY: (800) 735-2900

The Child Support Program (CSP) provides services for the State of Oregon. We cannot represent you
or give you legal advice. You may contact your own lawyer at any time. Low cost legal services may
be available. For information you may visit the CSP website at oregonchildsupport.gov.
The Child Support Program can provide you with information from forms and other notices in your own
language free of charge. This also includes Braille, large print, and the use of interpreters. To find out
more, contact your child support office.

Page 3 of 3 - HEARING REQUEST FOR SUPPORT PAYMENT CREDIT ORS 25.020; OAR 137-055-5240
CSF 01 0323 (Rev. 10/22/13)