) IN CIRCUIT COURT )ss: COUNTY OF __________________ ) ____________ JUDICIAL CIRCUIT __________________________________________________________________________ ) ______________________________, ) File No. ___________ Obligee, ) vs. ) PETITION FOR ORDER AND JUDGMENT ) AWARDING LATE FEES PER ______________________________, ) SDCL 25-7-38 Obligor. ) _________________________________________________________________________ STATE OF SOUTH DAKOTA COMES NOW, the Obligee and does hereby state, under oath, as follows: 1. My current full name and physical address are as follows: __________________ _________________________________________________________________. (Enter your first, middle and last name and your street address) 2. The full name of the Obligor is _______________________________ and his/her (Enter the first, middle and last name of the Obligor) physical address is as follows: ________________________________________ _________________________________________________________________. (Enter the complete street address of the Obligor) 3. The Obligor and I are parents of the following child(ren): Full Legal Name: _________________________________ (Enter the first, middle and last name of first child) Date of Birth: ______________________________ (Enter the date of birth of first child) _________________________________ (Enter the first, middle and last name of second child) ______________________________ (Enter the date of birth of second child) _________________________________ (Enter the first, middle and last name of third child) ______________________________ (Enter the date of birth of third child) _________________________________ (Enter the first, middle and last name of fourth child) ______________________________ (Enter the date of birth of fourth child) 4. On _________________________________, the Obligor was ordered to pay me (Enter the date the child support order was signed) $____________________ per month in child support payments for the support (Enter the amount the Judge ordered the other party to pay you) UJS-128 ­ Petition for Order and Judgment Awarding Late Fees Per SDCL 25-7-38 Rev. 06/2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 and maintenance of the above named child(ren). The child support payments are due and payable to __________________________________________________ (Enter the name of the person/place to whom the payments are to be paid to) on the ___________________ day of each and every month, starting (Enter the day of the month the other party was ordered to make his/her support payments) _______________________________. The child support order is attached and (Enter the date (month/day/year) that the support payments began by court order) incorporated herein by reference as Exhibit "A." 5. In the last 12 months before filing this document, I have received the following child support payments (fill in all columns for each payment): Amount Due: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Amount Received: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Date Received: ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ An Affidavit of Arrears from the Department of Social Services, Office of Child Support Enforcement, if available, is attached and incorporated herein by reference as Exhibit "B." WHEREFORE, I request the following: 1. That Obligor be found to be chronically delinquent in child support payments as required under our order for support; 2. That Obligor be ordered to pay a late fee equal to ten percent of the ordered child support or fifty dollars, whichever is greater, for each month in the preceding twelve months that the payment was ten or more days delinquent or Page 2 of 3 UJS-128 ­ Petition for Order and Judgment Awarding Late Fees Per SDCL 25-7-38 Rev. 06/2012 American LegalNet, Inc. www.FormsWorkFlow.com the payment was less than the ninety percent of the ordered child support, per SDCL 25-7-38; and 3. Any other relief as deemed appropriate by the Court. DATED this _______ day of _______________________, 20______. ____________________________________ Obligee (Your Signature) ____________________________________ Print your name ____________________________________ Your mailing address ____________________________________ City, State, ZIP code ____________________________________ Your Telephone number VERIFICATION STATE OF SOUTH DAKOTA ) COUNTY OF ________________ : SS ) Obligee, ___________________________________, being first duly sworn, deposes (Enter your first, middle and last name) and states that he or she verifies the facts expressed within the Petition for Order and Judgment Awarding Late Fees Per SDCL 25-7-38 are true. Dated this ______ day of ___________________, 20_____. _____________________________________ Obligee's Signature Subscribed and sworn to before me this ______ day of ______________, 20____. _____________________________________ Notary Public/Clerk of Court (SEAL) If Notary, my commission expires:_____________ Page 3 of 3 UJS-128 ­ Petition for Order and Judgment Awarding Late Fees Per SDCL 25-7-38 Rev. 06/2012 American LegalNet, Inc. www.FormsWorkFlow.com