AS 18.66.100(c)(12) AS 25.27.020, .062, .080 Page 1 of 8 DV-200 ()(cs) TEMPORARY CHILD SUPPORT ORDER (DOMESTIC VIOLENCE) Civil Rule 90.3 THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) PETITIONER (protected person), M F ) Birthdate: ) Petitioner is a child. Who is signing for the child? ) Name: Birthdate: ) Relationship to child: ) v. ) ) Case No. CI ) RESPONDENT (restrained person), M F ) Birthdate ) TEMPORARY Respondent is a child. Who is signing for the child? ) CHILD SUPPORT ORDER Name: Birthdate: ) DOMESTIC VIOLENCE Relationship to child: ) ) 1.Children. This order affects the following children: Full Names of Children Birth Dates 2.Physical Custody. The court finds that physical custody of the above children for theterm of this order has been awarded as follows: Primary Shared Divided Hybrid (For divided custody, fill in both a and b. For hybrid custody, fill in a, b, and c.) Primary Custody (child lives with this parent more than 70% of the year) a.Mother,, will have primary physical custody of the following child(ren): b.Father ,, will have primary physical custody of the following child(ren): Shared Custody (child lives with each parent at least 30% of the year) c.The parents will share physical custody of the following child(ren): The child(ren) will reside with during the following periods: which equals % of the year, and with during the following periods: which equals % of the year. Failure to take physical custody of the child(ren) at least 30% of the year is grounds for modification of this support order. However, denial of visitation by the custodial parent is not cause to increase child support. Civil Rule 90.3(b)(1)(E) American LegalNet, Inc. www.FormsWorkFlow.com AS 18.66.100(c)(12) AS 25.27.020, .062, .080 Page 2 of 8 DV-200 ()(cs)TEMPORARY CHILD SUPPORT ORDER (DOMESTIC VIOLENCE) Civil Rule 90.3 3.Child Support. The court finds that the obligor,, has a legal obligation to support the above children. It is ordered that the obligor shall pay child support for the children named above asfollows: (Put the current number of children on the first line. Subtract one number oneach subsequent line and do the calculations for each line.) Number ofBasic Monthly Health Insurance Total Monthly Children Amount Owed Adjustment (2666) Amount Owed Except as provided below, as each child reaches the age of 18, is otherwise legally emancipated or dies, the amount of support will change to the next lower amount. Support must continue while each child is 18 years old if the child is (1) unmarried, (2) actively pursuing a high school diploma or equivalent level of technical or vocational training, and (3) living as a dependent with the obligee parent or guardian or a designee of the parent or guardian, unless the following box is checked: Child support will end when each child reaches age 18. The first payment is due no later than . Subsequent payments are due no later than the 1st day of each month thereafter. 4.Extended Visitation Credit (available only in primary custody situations). Primary physical custody of the children listed in paragraph 2(a) or 2(b) has been givento the non-obligor parent. However, the obligor parent shall have physical custody ofthese child(ren) for the following periods of over 27 consecutive days: If this visitation is exercised, child support is reduced for the above period(s) as follows: (This reduction may not exceed 75% of the amount owed for the period.) If this visitation is not exercised, child support is not reduced. [Civil Rule 90.3(a)(3)] 5.Application of Civil Rule 90.3 Formula.The amount of child support in paragraph 3 was determined pursuant to: a. The formula in Civil Rule 90.3(a) or (b). b. c. incarcerated. unable to work because other d. 90.3(c)(1). The court finds good cause upon proof by clear and convincingevidence that manifest injustice would result if the support award were not varied.Reason(s) for the variation: American LegalNet, Inc. www.FormsWorkFlow.com AS 18.66.100(c)(12) AS 25.27.020, .062, .080 Page 3 of 8 DV-200 ()(cs) TEMPORARY CHILD SUPPORT ORDER (DOMESTIC VIOLENCE) Civil Rule 90.3 The amount of support that would have been required but for the 90.3(c)(1) variation is $ for children per month to be paid by the mother father. The estimated value of any property conveyed instead of support calculated under 90.3 is $ . 6.Medical Support Order. AS 25.27.060(c) and Civil Rule 90.3(d)(1). This orderconcerns health insurance for the child(ren) covered by this child support order. It doesnot concern health insurance for any other children or for the parents. a.Current Coverage. The obligor obligee must purchase health insurance for the child(ren) because such insurance is available at reasonable cost through his/her employer, union or otherwise. Name and address of employer/union through which insurance will be purchased: The insurance cost (currently $ per month) will be divided between the parties equally unless a different division of the cost is ordered. The child support calculation in paragraph 3 includes: a credit of $ per month (50% of the cost to the obligor) for health insurance purchased for the child(ren) by the obligor. If the obligor fails to purchase the insurance, the monthly child support obligation will increase by this amount, without further order of the court, until the obligor purchases the insurance and provides proof of the purchase to the other parent and to the Child Support Services Division (CSSD) if CSSD is handling collections. an extra $ per month (50% of the cost to the obligee) for health insurance purchased for the child(ren) by the obligee. If the obligee fails to purchase the insurance, the monthly child support obligation will decrease by this amount, without further order of the court, until the obligee purchases the insurance and provides proof of the purchase to the other parent and to the Child Support Services Division (CSSD) if CSSD is handling collections. If the cost of the insurance changes, the amount of the child support obligation will be adjusted accordingly, without further order of the court. The parent purchasing the insurance shall provide documentation of the change to the other parent and to the Child Support Services Division (CSSD) if CSSD is handling collections. If either parent believes the cost of the insurance has become unreasonable, that parent may file a motion asking the court to suspend the requirement that insurance be purchased. The children are eligible for services through the Indian Health Service military medical benefits but these services are not available in the area where the children live. Therefore, insurance must be purchased as stated above until these services become available. American LegalNet, Inc. www.FormsWorkFlow.com AS 18.66.100(c)(12) AS 25.27.020, .062, .080 Page 4 of 8 DV-200 ()(cs)TEMPORARY CHILD SUPPORT ORDER (DOMESTIC VIOLENCE) Civil Rule 90.3 The children are eligible for services through the Indian Health Service military medical benefits and these services are available to the children. Therefore, no additional insurance is required while these services are available. Health insurance for the child(ren) is not now available at reasonable cost or its availability is unknown. b.Future Coverage. If there is no health care coverage for the child(ren) and insurance becomes available to a parent at a reasonable cost, that parent mustpurchase the insurance after giving notice to the other parent. The cost of theinsurance must be divided between the parents equally unless a different divisionof the cost is ordered. Without further order of the court, the monthly childsupport obligation will increase by 50% of the cost of the insurance if the obligeepurchases it and decrease by 50% of the cost of the insurance if the obligorpurchases it, unless otherwise ordered. If the parents disagree about whetherthe cost of insurance is reasonable or about which insurance policy should bepurchased, either parent may file a motion asking the court to resolve thedispute. c.Information for Other Parent. The parent purchasing the insurance must notify the insurance company that the other parent can appl