Fill in a Valid Massachusetts Am 3 Form

IMPORTANT! You can request equitable adjustment of arrears owed to the Commonwealth only.

Arrears owed to a custodial parent are not eligible for equitable adjustment.

Check List of Required Items

The following documentation must be submitted with your application or your application will be returned as incomplete. Indicate if any of the items are not applicable by writing N/A. DOR may require you to provide additional documentation as the evaluation of your request proceeds.

Unless DOR has specifically asked for the original document, please submit copies only. DOR will not return any documents to you.

Completed Request for Equitable Adjustment (this two-page form).

Completed Statement of Financial Condition.

Verification of Income

Complete pay stubs for the past 3 months, or financial statements for the past 2 years if you are self-employed.

Information from the Social Security Administration (SSA).

Social Security Earnings Statement (required for all applicants). Go to www.ssa.gov for instructions on requesting an Earnings Statement. If you receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), attach a copy of the award letter.

Bank Information

Complete bank statements for all checking, savings and other bank accounts for the past 3 months.

Medical Records

Copies of any doctors’ letters, reports or medical records that support any claim of medical disability.

Power of Attorney

Power of Attorney if this offer is submitted by a designated representative.

Authorization to Request Consumer Credit Report

I, ____________________, hereby authorize DOR to obtain, and all consumer credit reporting agencies to furnish,

my full credit report in accordance with §§ 1681b(a)(2), (4) and (5), 1681b(f), 1681e and any other applicable sections of the Fair Credit Reporting Act (FCRA). (15 USC § 1681 et. seq.). I agree that DOR’s use of my credit report for collection and enforcement of my child support order is a permissible purpose as that term is defined in § 1681b of the FCRA. This authorization does not expire and any revocation of this authorization must be made in writing to DOR. Copies of this authorization are as good as the original.

Mail your completed and signed application, with copies of all required documents, to:

Department of Revenue

Child Support Enforcement Division

Attn:

AM-3 2/23/10

REQUEST FOR EQUITABLE ADJUSTMENT

To the Deputy Commissioner of the Child Support Enforcement Division (DOR):

1.I submit this request for equitable adjustment of past-due child support that I owe to the Commonwealth of Massachusetts. DOR’s records indicate and I believe that I owe a total of $___________ to the Commonwealth, including interest and penalty.

2.I understand that any past-due child support owed to the custodial parent is NOT subject to equitable adjustment and that even if this request is approved, DOR will continue its enforcement actions to collect any past-due support owed to the custodial parent.

3.Submission of this request for equitable adjustment does not waive any rights I might have to challenge the amount stated in paragraph 1 in the event no equitable adjustment is made.

4.I have attached a completed Statement of Financial Condition which shows that I do not have the present financial ability to pay the past-due support in full.

5.The past-due support I owe to the Commonwealth should be equitably adjusted because (check all that apply):

a. The past-due support accrued during periods I received needs-based benefits (e.g., SSI,TANF/AFDC, state

veterans’ benefits). Type of benefit: ________________________________ Dates received: ___________________

b. The past-due support accrued during periods I was unable to pay my child support because:

I had the following disability: _____________________________________________________________________

Dates of disability: ________________________ Received SSDI  Yes  No Injured at work  Yes  No

I was unemployed and did not receive unemployment benefits.

Reason for unemployment: ______________________________________________________________________

Dates of unemployment: ________________________

I was incarcerated. Dates and place of incarceration: __________________________________________________

Other. Please explain: __________________________________________________________________________

_____________________________________________________________________________________________

If you checked any box in Paragraph 5b: Did you file for modification of your support order during the period you were

unable to pay support?  Yes  No Explain: ______________________________________________________________

 c. I have custody of the minor child for whom I owe support.  Yes  No Attach custody order or proof of residence.

d. I am reconciled and reside with the custodial parent and the minor child for whom I owe past-due support. Date of reconciliation/marriage: __________ Has support order been terminated by the court?  Yes  No

I certify under the pains and penalties of perjury that the information provided above is true and accurate to the best of my knowledge and belief. I understand that if I fail to provide complete information or provide false information, my request for equitable adjustment will be denied. I also understand that DOR may continue its enforcement actions while this request for equitable adjustment is under consideration.

AM-3 2/23/10