IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. Plaintiff(s)/Petitioner(s) Defendant(s)/Respondent(s) Illinois Dept. of Public Aid is, or has been, granted leave to intervene. IDPA Case No. Definitions: Obligor: An individual who owes a duty to make support payments pursuant to an Order for Support. Obligee: An individual to whom a duty of support is owed or the individual's legal representative. Payor: Any payor of income to an obligor. Unallocated support: A total amount for maintence and child support and not a specific amount for either. File Stamp ORDER FOR SUPPORT Initial Order Modification The Court Finds: (a) The net income of the obligor on the date of this order is per (b) The amount of arrearage on the date of this order is for child support and for maintenance or unallocated support. (c) The child support cannot be expressed exclusively as a dollar amount because all or a portion of the obligor's net income is uncertain as to source, time of payment, or amount. It is ordered that , Obligor, is to provide. MAINTENANCE OR UNALLOCATED SUPPORT Payment Amount: Current Maintenance or Unallocated Support Payment: Arrearage Payment: Payment frequency: and every week every other week monthly twice each month on the every year Other Payment begins on: (date) Circuit Court or the State Disbursement Unit. . This is the first date that payment is to be received by the Clerk of the (Do not complete this Section if Unallocated Support is ordered.) CHILD SUPPORT Payment Amount: Current Child Support Payment: Arrearage Payment: every week every other week monthly twice each month on the Payment frequency: every year Other Payment begins on: (date) Circuit Court or the State Disbursement Unit. and . This is the first date that payment is to be received by the Clerk of the (Complete this Section only if finding (c) is checked above) PERCENTAGE AMOUNT OF CHILD SUPPORT In addition to the specific dollar amount of support ordered above, current child support shall be paid in the amount of % of obligor's payable The Obligor is further ordered to provide the obligee, within 7 days of receipt of income subject to this percentage assessment, income records sufficient to determine and enforce the percentage amount of child support. Payment begins on: (date) Circuit Court or the State Disbursement Unit. . This is the first date that payment is to be received by the Clerk of the P5-D-002 (05/09) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. Payment arrangements include: (Check only One.) (Payment must be sent to the STATE DISBURSEMENT UNIT if this box is checked.)A Notice to Withhold Income shall issue immediately and shall be served on the employer at the address listed in this Order. Payments shall be made to the State Disbursement Unit and sent to the State Disbursement Unit at P.O. Box 5400, Carol Stream, IL 60197. Payments must include Case Number, County of the Court issuing this Order, and Obligor's name and Social Security Number. Any subsequent employer may be served with a Notice to Withhold Income without further order of Court. OR The parties have entered into a written agreement providing for an alternative arrangement for the payment of support that is approved by the Court and attached to this Order, meeting all requirements of, and consistent with applicable law. An income withholding notice is to be prepared and served only if the obligor becomes delinquent in paying the Order for Support. Payments shall be made in accordance with the written agreement of the parties attached hereto. In the event the income withholding notice is served, payments shall be made to the State Disbursement Unit as set forth above. OR State law does not require payment to the State Disbursement Unit, and the parties have not entered into a written agreement as provided above. Payments shall be made payable to Clerk of the Circuit Court - Kane County and sent to the Clerk of the Circuit Court at P.O. Box 112 Geneva, IL, 60134 Attn. Child Support. Payments must include County of the Court issuing this Order, and Obligor's name and Social Security Number. In addition to and separate from amounts ordered to be paid as maintenance or child support, the obligor shall pay a $36.00 per year Separate Maintenance and Child Support Collection Fee. This sum shall be paid directly to the Clerk of the Circuit Court of Kane County at P.O. Box 112 Geneva, IL, 60134 and NOT to the State Disbursement Unit. DELINQUENCY If the obligor becomes delinquent in the payment of support after the entry of this Order for Support, the obligor must pay, in addition to the current support obligation, the sum of (a) for child support per the payment frequency ordered above for child support, and (b) for maintenance or unallocated support per the payment frequency ordered above for maintenance or unallocated support until the delinquency is paid in full. (This additional amount of (a) and (b), shall not be less than 20 percent of the total of the current support amount and the amount to be paid periodically for payment of any arrearage stated in the Order for Support.) A support obligation, or any portion of a support obligation which becomes due and remains unpaid for 30 days or more shall accrue interest at the rate of 9% per annum. TERMINATION This obligation to pay child support terminates on unless modified by written Order of the Court. (Insert a date no earlier than the date that the youngest child reaches the age of 18 or is expected to graduate from high school, whichever comes later.) This termination date does not apply to any arrearage that may remain unpaid on that date. The child/ children covered by this order is/are: INSURANCE The obligor, obligee, obligor and obligee shall provide health insurance for the child(ren) either by enrolling them in any health insurance coverage available throuth the obligor's, obligee's, obligor's and obligee's employment or securing private health insurance policy, accepted by the obligor and obligee or approved by the Court, which names the child(ren) as beneficiary. Both the obligor and the obligee shall be provided a copy of the insurance policy and insurance card. The name of the health insurance provider and the number of the insurance policy regarding dependant benefits/coverage are as follows: Name of Health Insurance Provider(s): Policy No.(s): IT IS FURTHER ORDERED THAT: The obligor must notify, in writing, the Clerk of the Court, and if a party is receiving child and spouse services under Article X of the Illinois Public Aid Code, to the Department of Public Aid within seven days of: 1. Any new residential, mailing address or telephone number; P5-D-002 (05/09) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. 2. 3. The name, address and phone number of any new employer, and; The policy name and identifying number(s) of health insurance coverage available. The obligor shall submit a written report of termination of employment and of new employment, including name and address of the new employer, to the Clerk of the Court and the obligee within 10 days. Obligor and obligee shall advise each other of a change of residence within 5 days except when the Court finds that the physical, mental or emotional health of a party or that of a minor child, or both, would be seriously endangered by disclosure of the party's address. An obligee receiving payments through income withholding shall notify, in writing, the Clerk of the Court and the State Disbursement Unit within 7 days, of a change of residence. The obligor and obligee shall report to the Clerk of the Court any change of information included in the Child Support Data Sheet (Exhibit 1) within 5 business days of such change. ADDITIONAL CONDITIONS OR FINDINGS Child Support payment amount deviates from the amount required by statutory minimum guidelines. The amount of support that would have been required under the guidelines is Reason for deviation: Other The "Child Support Data Sheet" attached hereto, as Exhibit 1, is a part of this Order. It is ordered that the Circuit Clerk Impound Exhibit 1, except to as the Parties, Attorney of Record, the Circuit Clerk personnel or any other person deemed interested by the Court, until further Order of this Court. FAILURE TO OBEY ANY OF THE PROVISIONS OF THIS ORDER MAY RESULT IN A FINDING OF CONTEMPT OF COURT Date: Judge: Attorney/Pro Se: Address: City, State and Zip: Telephone No.: Atty. Registration No.: P5-D-002 (05/09) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. CHILD SUPPORT DATA SHEET OBLIGOR INFORMATION OBLIGEE INFORMATION Last Name: Last Name: First Name: Complete Residential Address: Middle Initial: First Name: Complete Residential Address: Middle Initial: Complete Mailing Address (If other than above): Complete Mailing Address (If other than above): Date of Birth: Date of Birth: Driver's License No.: Driver's License No.: * Social Security No.: * Social Security No.: Home Phone No.: Employer(s) Name/Company: Home Phone No.: Employer(s) Name/Company: Employer(s) Address: Employer(s) Address: Employer(s) ID No.: Employer(s) ID No.: Work Phone No.: Work Phone No.: LAST CHILD/CHILDREN INFORMATION FIRST M. I. DATE OF BIRTH SOCIAL SECURITY NO. (If more space is needed, please attach an additional sheet) * If obligor/obligee is not a US citizen, so indicate and provide the obligor's/obligee's alien registration number, passport number and home county's Social Security or National Health Number Exhibit 1 P5-D-002 (05/09) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com