IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION Petitioner: ______________________________ Civil Action File No: And Respondent:____________________________ CONSENT TO CHANGE OF CUSTODY AND CHILD SUPPORT 1. I, __________________________________, am the mother/father of the child(ren) named: . 2. I consent in writing to the following custody arrangement: a) That the father/mother of said child(ren) have sole legal and sole physical custody of the child(ren). b) That the father/mother of said child share joint legal custody with me and I will be the primary physical custodian from _________________________ to ___________ and the mother/father shall be the secondary physical custodian from _____________________(date) to ______________________ (date). c) That the father/mother of said child share joint legal custody with me and mother/father shall be the primary physical custodian from ______________________ to ___________________and I will be secondary physical custodian from______________to __________________________________. 3. □I consent in writing to the following visitation arrangement attached hereto as Exhibit “A”. 4. □I consent to child support being modified as follows: a) My gross monthly income is __________________ . b) The mother’s/father’s gross income is____________________ . c) Child support is being determined for _____ number of children. NOTICE: The new Georgia Child Support Guidelines went into effect on 1/1/07. Any child support calculations must now be made using the new guidelines. To obtain forms and instructions, go to: https://services.georgia.gov/dhr/cspp/do/public/SupportCalcDownload or go to the menu for the Change of Custody and Child Support and click on the link to the website. e) No special circumstances exist, or the following special circumstances exist and check those applicable: Consent to Change of Custody-01/07 ©2007 Fulton County Superior Court Family Division Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Ages of the child(ren). A child(ren)’s extraordinary medical costs or needs in addition to accident and sickness insurance, provided that all such costs or needs shall be considered if no insurance is available. Educational costs. Day-care costs. Shared physical custody arrangements, including extended visitation. A party's other support obligations to another household. Income that should be imputed to a party because of suppression of income. In-kind income for the self-employed, such as reimbursed meals or a company car. Other support a party is providing or will be providing, such as payment of a mortgage. A party's own extraordinary needs, such as medical expenses. Extreme economic circumstances including but not limited to: 1) Unusually high debt structure; or 2) Unusually high income of either party or both parties, which shall be construed as individual. Historical spending in the family for child(ren) which varies significantly from the percentage table. Considerations of the economic cost-of-living factors of the community of each party, as determined by the trier of the fact. In-kind contribution of either parent. The income of the custodial parent. The cost of accident and sickness insurance coverage for dependent children included in the order. Extraordinary travel expenses to exercise visitation or shared physical custody. Any other factor which the trier of fact deems to be required by the ends of justice, as described below:___________________________________________________________________ ____________________________________________________________________________. f) ____________________________ (person’s name) shall pay to ______________________ (person’s name) child support in the amount of ____________________ per week/biweekly/semimonthly/monthly. 5. I make this consent freely, and knowingly. I have not been forced to sign this consent and I am not under any duress at the time that I am signing this consent. This the ___________________ day of _____________________, ______. [day] [month] [year] (Sign your name here in front of the Notary) Name (print or print) ______________________ __, Pro Se Address _________________________________________________________________________________ Telephone number: ( _______________________________ ) Sworn to and subscribed before me this ____day of ____________________ , ______. Notary Public My Commission expires: (Notary Seal) Consent to Change of Custody Form-01/07 ©2007 Fulton County Superior Court Family Division Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com