IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF __________________ In the Matter of: ________________________________, Petitioner, and ________________________________, Respondent, and □ ________________________________, Child who is at least 18 and under 21 years of age, unmarried and unemancipated. (ORS 107.108) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) Case No. ______________________ STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT; AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] Based upon the request and stipulation of the parties, as shown by the notarized signatures below, and it appearing to the Court that a judgment of annulment, dissolution of marriage, separation, or establishing paternity, custody and parenting time was granted in this case on , 20 , in case number , in the County Circuit Court, that the parties jointly request a modification of the custody, parenting time and/or child support provisions of this judgment; Now, therefore, IT IS HEREBY ORDERED that: 1. Custody: a. □ The judgment with respect to custody remains in effect and unchanged. b. □ Petitioner □ Respondent is awarded sole custody of the child/ren: (Names and dates of birth), c. □ The parties have agreed to joint custody of the following child/ren: (Names and dates of birth), as described in the attached parenting plan, labeled “Exhibit 1.” 2. □ Father □ Mother shall have parenting time with the child/ren in accordance with ☐ the attached parenting plan, labeled “Exhibit 1”, or as follows: □ Neither parent shall move to a residence more than 60 miles further distant from the other parent without giving the other parent reasonable notice of the change of residence and providing a copy of such notice to the court, or □ the requirement of ORS 107.159 regarding notice of move is suspended for good cause found. /// STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 1 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) 3. Child Support, including Cash Medical Support. a. □ Child support as previously ordered remains in effect and unchanged. b. □ The Judgment is modified to terminate □ Petitioner’s □ Respondent’s support obligation effective for the child/ren: (name(s) and date(s) of birth) Check either A or B below: (A) □ No child support shall be ordered at this time because: □ An order for child support in the amount of $ monthly, □ including health care coverage, has already been ordered and docketed with the County Circuit Court, case number . □ Other reason: (B) □ Child support shall be paid by □ Petitioner to Respondent (or) □ Respondent to Petitioner beginning on the □ first or □ of the month following the date of the judgment and continuing on the same day of each month thereafter. The support for each child shall continue until the child reaches eighteen (18) years of age, or is otherwise emancipated, unless the child is a student attending school as defined by Oregon law, in which case support shall continue until the child reaches 21 years of age. Until further order, the total payment per month shall be $ for children. Cash Medical Support: Of the amount ordered above in paragraph 2B, $ is cash medical. The cash medical support amount ordered is in addition to any percentage of uninsured costs either of the parties is ordered to pay below in paragraph 4(C). (Check if applicable) □ Neither Petitioner or Respondent have appropriate private or public health care coverage available for the parties’ child/ren (see 4(3) below). Cash medical support □ is □ is not ordered and the court’s findings in this regard are as follows: □ Petitioner □ Respondent and/or □ Child/ren are eligible for public medical assistance and cannot be ordered to pay cash medical support. (Check if applicable) □ This order shall modify and replace the following existing order: (List court/agency and case no.) because the court finds that the existing order was issued by an Oregon court or agency, one of the parents or the child/ren receiving support under the order still resides in Oregon and circumstances have changed since this order was entered. 4. Child Support Calculation (Check any that apply). □ The child support worksheet on which the support amount was calculated is labeled “Exhibit "and attached to and incorporated in this judgment. □ The support award does not deviate from the amount presumed correct under the guidelines set outin the Oregon Administrative Rules. STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 2 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) □ The support amount presumed correct under the guidelines set out in Oregon Administrative Rules is $ . The support award deviates from this amount because this Court finds that application of the formula would be unjust or inappropriate in this case because of (check one or more that apply): □ Recurring medical expenses of □ Other 5. Health Care Coverage. (DO NOT FILL THIS SECTION OUT if the boxes in Paragraph 3(A) above have been checked stating that there is an existing child support order that includes health care coverage currently in effect.) A.) PRIVATE INSURANCE IS AVAILABLE □ Petitioner □ Respondent shall name the child/ren as beneficiaries of the following appropriate private health care coverage for the duration of the support obligation (describe type/s of coverage): B.) NO PRIVATE INSURANCE IS AVAILABLE NOW Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren. 1.) □ Petitioner □ Respondent is ordered to apply to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 2.) □ Petitioner □ Respondent has already applied to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 3.) □ The child/ren are currently enrolled in public health care coverage. This coverage shall be maintained. 4.) □ Petitioner, □ Respondent □ Both Petitioner and Respondent are ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. C.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES □ Petitioner should pay % and Respondent should pay % of the uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is in addition to any cash medical support ordered above in paragraph 2 as part of the child support award. NOTICE ABOUT PERIODIC REVIEWS If you are receiving child support services through the Department of Justice pursuant to option (a) above, either parent may request that the Department of Justice/Division of Child Support review the amount of support ordered after three years from the date the order took effect or at any time upon the occurrence of a substantial change of circumstances. 6. Payment of Child Support. Pursuant to ORS 25.378(1), an income withholding order shall be issued to enforce the child support obligation unless an exception is indicated below. □ Exceptions to withholding. Income withholding is not ordered at this time because there is no support arrearage, the paying parent has not previously been granted an exemption from withholding, and: □ The parents, and the State, if support rights are assigned, have agreed in writing to an alternative arrangement; or □ Good cause not to require withholding is found because there is proof of timely payment of previously-ordered support and income withholding would not be in the best interests of the child. STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 3 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) All payments of child support shall be made (check either (a) or (b) below): (a) □ To the Oregon Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 or □ by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). (b) □ Pursuant to the above exception, directly to □ Petitioner’s □ Respondent’s checking or savings account. A receipt of deposit shall be kept by the parent paying support as proof of payment. A canceled check is also prima facie evidence that payment has been made. The person receiving support shall provide the paying parent with current deposit slips and/or bank name, account name and account number. NOTICE ABOUT PARENTING TIME AND CHILD SUPPORT The terms of child support and parenting time (visitation) are designed for the child’s benefit and not the parents’ benefit. You must pay support even if you are not receiving parenting time. You must comply with parenting time and visitation orders even if you are not receiving child support. Violation of child support orders and visitation or parenting time orders is punishable by fine, imprisonment or other penalties. Publicly funded help is available to establish, enforce, and modify child support orders. Paternity establishment services are also available. Contact your local district attorney, the domestic relations court clerk, or the Department of Justice at 1-800-850-0228 or 503-378-5567 for information. Publicly funded help may be available to establish, enforce, and modify parenting time or visitation orders. Forms are available to enforce parenting time or visitation orders. Contact the domestic relations, civil court clerk or courthouse facilitator for information. NOTICE OF INCOME WITHHOLDING This support order is enforceable by income withholding under ORS 25.378 to 25.390, 25.414 to 25.372 and 25.375. Withholding shall occur immediately, whenever there is an arrearage at least equal to the support payment for one month, whenever the obligated parent requests such withholding, or whenever the obligee requests withholding for good cause. The District Attorney or, as appropriate, the Division of Child Support of the Department of Justice will assist in securing such withholding. Exceptions may apply in some circumstances. 7. Life Insurance Coverage for Child/ren. □ The judgment with respect to life insurance coverage for the parties’ children remains in effect and unchanged, or □ Petitioner □ Respondent shall obtain and maintain life insurance for the benefit of the child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $_________________________. 8. □ Petitioner □ Respondent shall be entitled to claim the following child/ren as dependent/s for tax purposes beginning the year this judgment is entered (list names): OR □ Other (specify): 9. Unchanged Terms of Judgment Remain in Effect. Any terms in the Judgment not changed by this Supplemental Judgment shall remain in full force and effect. /// /// /// /// /// /// STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 4 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) 10. Money Award. Child Support Obligation □ included □ not included. Additional information required by ORS 18.042 PETITIONER RESPONDENT Full Name Address or Contact Address Attorney’s Name, Telephone Number and Address (if applicable) Date of Birth Driver’s License Number and State of Issuance The following information is to be provided by any party entitled to receive a money award (a “judgment creditor”) as listed in this Judgment. Others Entitled to Portions of Judgment Payable to PETITIONER The following person(s) or public bod(ies) are known by Petitioner to be entitled to a portion of a payment made on the judgment (other than Petitioner’s attorney): □ None or □ Others Entitled to Portions of Judgment Payable to RESPONDENT The following person(s) or public bod(ies) are known by Respondent to be entitled to a portion of a payment made on the judgment (other than the Respondent’s attorney): □ None or □ Type of Judgment Child Support Award Amount of Judgment WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Spousal Support Award WHO PAYS □ Petitioner □ Respondent WHO RECEIVES $ □ Other: judgment. □ per month or □ Other: , starting on the □ first day or of the month following the date of the 1. $ per month or Other: , starting on the first day or □ Other: of the month following the date of the judgment, lasting until (date), or the death of either party, whichever comes first; or □ Petitioner □ Respondent 2. A lump sum payment of $ (date): to be paid by STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 5 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) Property Division (if applicable) WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent 1. $ per month, starting on the □ first day or □ Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date). Prejudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Postjudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Accrued Arrears (if any, on judgments to be paid on a periodic basis) Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees) WHO PAYS □ Petitioner □ Respondent $ . WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent Nine percent ( 9 %) per annum simple interest on the unpaid balance of the total judgment amount(s) of $ . Interest accrues from the date the judgment is entered and continues until fully paid. 1. $ per month, starting on the □ first day or □ Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date). $ . WHO RECEIVES □ Petitioner □ Respondent STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 6 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) Attorneys Fees (if any) WHO PAYS □ Petitioner □ Respondent $ . WHO RECEIVES □ Petitioner □ Respondent DATED this ________ day of ________________________________, 20______. Circuit Court Judge Print Name APPLICATION FOR FULL CHILD SUPPORT PROGRAM SERVICES: By signing below, I apply for child support services, including enforcement, from the Child Support Program(CSP). Check the box in Paragraph 6(a) if you are requesting accounting and disbursement services only. (Note: If you never received TANF, tribal TANF or AFDC in any state, an annual $25 fee will apply if over $500 is collected and distributed to the family each year.) □ Petitioner, Signature Date □Respondent, Signature Date All parties have stipulated (agreed) to the terms of this Judgment. Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on by , 20 , (date) (name of person(s)). Notary Public for ____________/Court Clerk My Commission Expires: /// STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 7 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08) Respondent, Signature State of County of ) ) This instrument was acknowledged before me on , 20 , (date) by (name of person(s)). Notary Public for ____________/Court Clerk My Commission Expires: □ If applicable, child who is at least 18 and under 21 years of age, has agreed (stipulated to the terms of this judgment: Child, Signature State of County of ) ) This instrument was acknowledged before me on , 20 , (date) by (name of person(s)). Notary Public for ____________/Court Clerk My Commission Expires: Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: □ I selected this document for myself and I completed it without paid assistance. □ I paid or will pay money to for assistance in preparing this form. Submitted by: □ Petitioner □ Respondent, Signature Address or Contact Address Print Name City, State, Zip I certify that this is a true copy: Telephone or Contact Telephone , □ Petitioner □ Respondent, Signature STIPULATION TO MODIFY □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT, AND American LegalNet, Inc. SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 8 of 8 www.FormsWorkFlow.com Modification-4C: ModStipJudgWithSupport4CVer12.doc (3/08)