FAMILY COURT _______ JUDICIAL CIRCUIT STATE OF HAWAI‘I [ ] CHILD SUPPORT ENFORCEMENT AGENCY, STATE OF HAWAI‘I, and [ ] MOTHER CASE NUMBER ORDER REGARDING MOTION TO MODIFY CHILD SUPPORT FC- NO. This document was prepared by: [ ] Petitioner/Plaintiff [ ] Defendant, [ ] Attorney for [ ]Petitioner/Plaintiff [ ]Defendant [ ] FATHER PETITIONER(S)/ PLAINTIFF(S), Name Address vs. City, State, Zip Code [ ] MOTHER [ ] FATHER [ ] CARETAKER [ ] MOTHER [ ] FATHER [ ] CARETAKER Telephone Number [ ] and CHILD SUPPORT ENFORCEMENT AGENCY, STATE OF HAWAI‘I, DEFENDANT(S). Motion Filed On: [ ] [ ] [ ] Presiding Judge: Date of Hearing: The parties, without a hearing, STIPULATE/AGREE to the following: The case came on for hearing, and the following parties were present at the hearing: [ ] Mother [ ] Attorney for Mother [ ] Father [ ] Attorney for Father [ ] Attorney for CSEA [ ] Other Although duly notified, failed to appear and the hearing proceeded by default. (Name) CHILDREN: This order applies to the following child(ren): NAME (First and Last) 1. 2. 3. 4. be: 1. SEX []M []F []M []F []M []F []M []F DATE OF BIRTH Based upon the representations of the parties and the legal record, IT IS HEREBY ORDERED that the Motion [ ] granted [ ]denied [ ]granted/denied in part. CURRENT CHILD SUPPORT: [ ]Father [ ]Mother shall pay child support in the amount of $ per child, per month, for a total of $ per month, starting from and continuing until the subject child(ren) become(s) 18 years old or until age 23, so long as said child(ren) is/are still in high school or enrolled full-time in an accredited educational or vocational institution, or until further order of the Court. The parent making the payments is called the “Payor Parent.” FOR COURT USE ONLY 01/2005 PAGE 1 of 3 ORDER REGARDING MOTION TO MODIFY CHILD SUPPORT American LegalNet, Inc. www.FormsWorkflow.com 2. 3. 4. [ ]Father’s [ ]Mother’s current child support obligation for (write child(ren)’s name(s)) shall be SUSPENDED as of . [ ]Father’s [ ]Mother’s current child support obligation for (write child(ren)’s name(s)) shall be TERMINATED as of . The issue regarding current child support obligation for (write child(ren)’s name(s)) shall be RESERVED as of . 5. [ ] This child support order is TEMPORARY until further order of the Court. 6. PAST CHILD SUPPORT: [ ]6a. OWING TO THE MOTHER/FATHER: Judgment shall enter against [ ]Father [ ]Mother for the sum of $ for past child support owing to [ ]Father [ ]Mother for the period(s) through . [ ]Father [ ]Mother shall pay the sum of $ each and every month commencing until the judgment is fully paid. [ ]6b. OWED TO THE DEPARTMENT OF HUMAN SERVICES (DHS): [ ] Judgment shall enter against Father for the sum of $ for past child support owing to the Department of Human Services (hereinafter “DHS”) for the period(s) through . In addition to any current child support ordered, Father shall pay the sum of $ each and every month commencing until the judgment is fully paid. [ ] [ ]6c. 7. Judgment shall enter against Mother for the sum of $ for past child support owing to the Department of Human Services (hereinafter “DHS”) for the period(s) through . In addition to any current child support ordered, Mother shall pay the sum of $ each and every month commencing until the judgment is fully paid. The issue regarding past child support owed by one parent to the other is RESERVED. MEDICAL INSURANCE: [ ]7a [ ]Father [ ]Mother shall provide medical health insurance coverage for the subject child(ren) and shall provide the other parent with proof of coverage within 30 days of the date of this hearing, if not already provided. [ ]7b [ ]7c 8 [ ]Father [ ]Mother does not have the present financial capacity of providing medical health insurance coverage for subject child(ren) and is hereby ordered to provide such coverage for said child when it becomes available through that parent’s employer or union. The issue regarding medical insurance coverage is RESERVED. FURTHER ORDERS: . 01/2005 PAGE 2 of 3 ORDER REGARDING MOTION TO MODIFY CHILD SUPPORT American LegalNet, Inc. www.FormsWorkflow.com 9. PAYMENTS: All payments are deemed as child support in accordance with the laws of the State of Hawai‘i. All payments ordered herein shall be made payable to and mailed to: CHILD SUPPORT ENFORCEMENT AGENCY, Lock Box , P.O. Box 1860, Honolulu, Hawai‘i 96805-1860. 10. METHOD OF PAYMENT: All payments for child support shall be made by way of an Order/Notice to Withhold Income for Child Support which shall be served on Payor Parent’s current employer as well as any successor employer. 11. DIRECT PAYMENT: Payor Parent shall make support payments, as ordered, directly to the Child Support Enforcement Agency (CSEA) until the Order to Withhold Income for Child Support commences. If for any reason, the withholding of income stops, the Payor Parent must resume payments to the CSEA as long as there is a continuing child support obligation. All payments made to the CSEA by the Payor Parent, shall be made with a money order, cashier’s check or certified check payable to “Child Support Enforcement Agency” and mailed to the address reflected in Paragraph 9 above. 12. COLLECTION OF SUPPORT, ARREARS OR DEBTS: In addition to any payment plan to liquidate the amounts owed as ordered in the above-entitled action or related administrative proceeding, CSEA is authorized to collect current support and/or the full amount of any support arrears or support debt through State and Federal tax refund interception, seizure of property, withholding of income, unemployment insurance benefits, worker’s compensation and retirement benefits, or any other lawful means of collection. CSEA’s collection efforts will continue until the support, arrears or debt is paid in full. Information relating to the support, arrears or debt may be disclosed to consumer credit reporting agencies. 13. NOTIFICATION TO CSEA: Parties shall notify CSEA, in writing at the address reflected in Paragraph 9, of any change in employment and /or residence address or telephone number, within 10 (ten) days of such change. DATE JUDGE’S SIGNATURE Mother’s Signature Father’s Signature Mother’s Name Printed Father’s Name Printed Mother’s Address Father’s Address City, State, Zip Code City, State, Zip Code Mother’s Social Security Number Father’s Social Security Number Mother’s Employer’s Name Father’s Employer’s Name Mother’s Employer’s Address Father’s Employer’s Address City, State, Zip Code City, State, Zip Code Signature of Mother’s Attorney Signature of Father’s Attorney Name of Attorney for Mother (Print) Name of Attorney for Father (Print) Signature of CSEA Attorney Other 01/2005 PAGE 3 of 3 ORDER REGARDING MOTION TO MODIFY CHILD SUPPORT American LegalNet, Inc. www.FormsWorkflow.com