Completing Form CAO 13-4: Agreed Order for Custody (Revised 5/20/2005) Exactly like you did in the Petition, at the top left-hand corner of page 1, fill in each of your names, addresses and telephone numbers. Fill in the county and judicial district in the heading in capital letters (for example, “IN THE DISTRICT COURT OF THE SIXTH JUDICIAL DISTRICT IN AND FOR THE COUNTY OF BANNOCK”). Fill in your full legal names in the caption above “Petitioners”. Fill in the Case Number. The Name of the Document. Check the boxes to indicate the orders you want. Leave the date blank in the introductory sentence. Minor Child/ren of the Petitioners. Fill in the name and date of birth for each minor child. 1A. Legal Custody. • Check the first box if both parents are fit persons to share the decision-making rights, responsibilities and authority relating to the health, education and general welfare of the child/ren. or • Check the second box if one parent is to have sole legal custody of the child/ren, and • Write the name of the parent in the blank who will have sole legal custody. 1B. Physical Custody. • Check the first box if both parents are to be awarded physical custody of the child/ren and o Attach a copy of the same Parenting Plan you attached to your Petition, marked “Exhibit A”. IMPORTANT: The Parenting Plan must be attached to make it a part of the Order for Custody. or • Check the second box if physical custody of the child/ren will be awarded to only one parent, and • Write the name of the parent in the blank who will have sole physical custody. o Check the box if the other parent will have time with the child/ren, write in the parent’s name and o Write in the terms and conditions of the other parent’s time with the child/ren. 2. Child Support. If there is already a Child Support Order and there has been no change in circumstances that would require the child support amount to be changed, check the first box. Make a copy of that Order, mark it as “Exhibit B” and attach it to this Order. If there is already a Child Support Order and a change in circumstances will cause the child support amount to be changed, also check the box to select the next paragraph. If there is NOT a Child Support Order or if the current Child Support Order needs to be changed, check the box to select this paragraph. AGREED ORDER FOR CUSTODY PAGE 1 CAO 13-4 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com You will first need to complete an Affidavit Verifying Income and a Child Support Worksheet. A Court Assistance Officer can help you generate these documents if you provide the required information. The Child Support Worksheet will be used to complete this section. • Write in the name of the parent who will pay child support and the total monthly amount (the base amount of support plus or minus any adjustments for medical insurance premiums and/or the tax dependency). • If your child support calculation includes the paying parent’s share of medical insurance premiums and/or tax benefits, o Fill in the Base Amount of child support o Check the appropriate boxes and fill in the amount. • If you have more than one minor child, you will need to have a separate calculation to reflect the changed amount of support as each child is emancipated (no longer eligible for support under Idaho law). Fill in the total amount of child support, as calculated according to the Idaho Child Support Guidelines. • Attach your Affidavit Verifying Income and Support Worksheet(s) to the Petition, marking each as “Exhibit B”. Extended Visits. If the child/ren will be living in the home of one parent at least 75% of the time, you can adopt either or both of the next two paragraphs of the form. If the child/ren spends more than 25% of the overnights in a year with each parent (shared physical custody), ignore the next two paragraphs of the form. NOTE: Section 10(e) of the Idaho Child Support Guidelines, Rule 6(c)(6) of the Idaho Rules of Civil Procedure describe “Shared Physical Custody” and computation of child support with that parenting arrangement. You can get a copy of the Child Support Guidelines from a Court Assistance Office or the Internet at http://www2.state.id.us/judicial/rules/ircp6c6.rul. • If you selected the first paragraph, indicate how much the support payment will be reduced by either checking the box for 50% or filing in your own percentage as you did on the Petition. 3. Medical Insurance. Check the first, second or third box to indicate how health insurance coverage for the child/ren is now being provided. If you selected the first paragraph, write in the name of the parent(s) currently providing health insurance. In the fourth paragraph, if health insurance premiums are NOT included in the calculation of child support, check the box and write in the percentage to be paid by each parent, based on each of your Guidelines income percentage. (These percentages are determined when calculating the child support. Refer to the Child Support Worksheet). 4. Health Care Costs Not Paid by Insurance. Write in the percentage to be paid by each parent, based on their Guidelines income. 5. Net Work-related Child Care Costs. If you did not include this amount in your child support calculations, check the box and • Fill in the percentages each parent will pay. • Check the box if both parents will pay the care provider directly. AGREED ORDER FOR CUSTODY PAGE 2 CAO 13-4 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com 6. Income Tax Exemption. Write in the blank the parent’s name who will claim each child as a dependent on their income tax return(s). Note: The child support calculation must reflect the same designation. 7. Name Change. If you want to have the last name of your child/ren changed and/or want to have your child/ren’s birth certificate(s) changed, the Bureau of Vital Statistics in the state where your child/ren was born will require a court order. • If you want a court order to change the last name of your child/ren, check the box and • Write in the last name. (Accurate spelling is very important.) • If you want the court to order that your child/ren’s last name be changed on the child/ren’s birth certificate, check the box. 8. Amend Birth Certificate. When the Court determines paternity, the Bureau of Vital Statistics in the state where your child/ren was/were born will add the father’s name to your child/ren’s birth certificate. • Write in father’s full legal name as it should appear on the child/ren’s birth certificate. Leave the date blank. The judge will fill in the date when s/he signs the Order for Custody. Clerk’s certificate of service: Fill in name, mailing address, city, state and zip code for Father and Mother. Leave the date blank. The clerk will fill it in when s/he signs the certificate. Exhibits: Attach all required Exhibits to the Order for Custody (with a staple). The Exhibits will include any: Parenting Plan (Exhibit A), and Child Support Order from another case (Exhibit B). Make three more copies of the Order for Custody (total of 4) with all the Exhibits attached. REMEMBER TO REMOVE THESE INSTRUCTIONS BEFORE SUBMITTING THE ORDER TO THE COURT! AGREED ORDER FOR CUSTODY PAGE 3 CAO 13-4 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com ______________________________________ Full Name of Father Mailing Address (Street or Post Office Box) City, State and Zip Code Telephone Number ______________________________________ Full Name of Mother Mailing Address (Street or Post Office Box) City, State and Zip Code Telephone Number IN THE DISTRICT COURT OF THE JUDICIAL DISTRICT OF THE STATE OF IDAHO, IN AND FOR THE COUNTY OF In Re the Children of: _____________________________________, Father, and _____________________________________, Mother, Case No. ___________________________ ORDER FOR [ ] PATERNITY [ ] CUSTODY,VISITATION [ ] CHILD SUPPORT Petitioners. This matter came before the court on the ________ day of _______________________, _________ on the Stipulated Petition for Custody of the father and mother. It appears from the records and files of this action that the Petitioners have agreed and stipulated to the entry of this Order. 1. The following child/ren under the age of eighteen (18) years, or nineteen (19) years and still pursuing a high school education, was/were born to or adopted by the petitioners: AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 1 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com Name __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Date of Birth _______________________ _______________________ _______________________ _______________________ _______________________ The court has jurisdiction to determine custody of the minor child/ren pursuant to the Uniform Child Custody Jurisdiction and Enforcement Act, Idaho Code Section 32-11-101, et seq. because Idaho was the home state of the minor child/ren on the date of filing the Petition. The court has jurisdiction to enter a Child Support Order as set forth in Title 32, Chapter 7, Idaho Code. IT IS ORDERED: 1. Custody. A. Legal Custody. [ ] Both parents are awarded joint legal custody of their minor child/ren. [ ] ____________________________ is awarded sole legal custody of their or child/ren. B. Physical Custody. [ ] Both parents are awarded joint physical custody of their child/ren on the terms and according to the Parenting Plan which is attached as “Exhibit A”. or [ ] _________________________ is awarded sole physical custody of their minor child/ren. [ ] ____________________________ shall have time with the child/ren as follows: _______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________. or [ ] in accordance with the Parenting Plan which is attached as “Exhibit A”. AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 2 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com 2. Child Support. [ ] Child support has already been set in Case No. _________________________, entered in _________________ County, State of ____________________, on (month/day/year) ______________________________. or [ ] The Child Support Order entered on __________________________ is modified. [ ] Child support shall be paid by __________________________ in the total amount and/or of $______________ per month. The total amount includes: [ [ [ Base child support in the amount of: plus or minus a pro rata share of: ] Work-related childcare expenses in the amount of: ] Insurance premiums allocated in the amount of: ] Tax benefits allocated in the amount of: $__________ $__________ $__________ $__________ Child support payments shall begin on the twentieth (20) day of the month after the Order for Custody is signed and continue to be paid on the twentieth (20) day of each following month until the child/ren reaches the age of eighteen. If the child for whom support is being paid continues his/her high school education after reaching the age of eighteen (18) years, child support payments shall continue until the child discontinues his/her high school education or reaches the age of nineteen (19) years, whichever is sooner. Payment shall be made payable to the Department of Health and Welfare and sent to: Idaho Child Support Receipting, P.O. Box 70008, Boise, ID 83707-0108. [ ] The parents have more than one minor child. If this Child Support Order has not been modified, when one child is no longer entitled to support, child support for the remaining child/ren shall continue in the total amount of $___________ per month; when two children are no longer entitled to support, child support for the remaining child/ren shall continue in the total amount of $____________ per month; when three children are no longer entitled to support, child support for the remaining child shall continue in the total amount of $____________ per month. [ ] Extended Visits: Our child/ren live/s in the home of one parent at least 75% of the time. [ ] When the parent paying child support has physical custody of the child/ren for 14 or more overnights in a row, the amount of base child support shall be reduced for that period of time; however, visitation of two overnights or less with the other parent will not eliminate the reduction of base child support during extended visits. The child support reduction for the period AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 3 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com of the actual physical custody shall be [ ] 50% or [ ] _______% of the base child support obligation. The reduction shall be subtracted from the child support payment due the next month. [ ] If the parent paying child support has physical custody of some but not all of the children for 14 overnights in a row, before a reduction is made, the base child support obligation shall first be divided by the number of children under 18 years of age. The reduction for the paying parent shall only apply to the base child support thus allocated to the children in that parent's custody. (Example: Parent has 3 of 4 children for 14 overnights. $300/mo. base support payment divided by 4 children = $75 per child per month divided by 30 = $2.50 per day per child x 14 = $35.00 x 3 for 3 children = $105.00. Reduction = 50% of $105 or $52.50.) NOTICES According to Chapter 12, Title 32, Idaho Code, this Child Support Order is immediately enforceable through income withholding. Income withholding shall be enforced by a Withholding Order issued to the paying parent’s employer without additional notice to the paying parent. A statewide lien on all real and personal property of the paying parent will arise automatically if child support is past due in an amount equal to the smaller of $2,000 or 90 days of support, according to Idaho Code §§7-1206 and 45-1901, et.seq. The Support Order can also be enforced by license suspension. 3. Medical Insurance. [ ] is/are currently providing health insurance for the minor child/ren and shall continue to do so, so long as it is reasonably available through that parent’s employment. If such insurance becomes unavailable to the parent currently providing insurance, the parent first reasonably able to obtain group health insurance through employment shall do so. or [ ] Neither parent is currently providing health insurance for the child/ren. The parent first reasonably able to obtain group health insurance through employment shall do so. or [ ] The child/ren participate in the Children’s Health Insurance Program. The parent first reasonably able to obtain group health insurance through employment shall do so. [ ] The total child support amount does not include any actual cost paid by either parent for health insurance premiums for the child/ren. That cost, whether being paid now or incurred in the future, shall be prorated between the parents in proportion to their Guidelines income. Father shall pay ______ % and Mother shall pay _______ %. The payment shall be in addition to the base child support award and promptly paid directly between the parents. Where medical insurance is provided, each parent is ordered to provide the other with all medical insurance information necessary to obtain health care for the child/ren. Insurance AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 4 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com proceeds shall be applied first to unpaid medical bills and then to reimburse the paying parent for any prepaid medical costs. Both parents shall sign any needed document that provides continuing health care for their child/ren. Notice Failure to provide medical insurance coverage may result in the direct enforcement of a medical support order by either the obligee (party or parent other than the parent ordered to carry or provide a health benefit plan for the parties' minor child/ren) or the Department of Health and Welfare. A national medical support notice will be sent to your employer, requiring your employer to enroll the child in a health benefit plan as provided by Sections 32-1214A through 32-1214J, Idaho Code, and applicable rules of the department. 4. Health Care Costs. The actual cost paid by either parent for health care expenses for the child/ren not covered or paid in full by insurance, including, but not limited to orthodontic, optical and dental, shall be prorated between the parents. ______ % shall be paid by Father and _______ % shall be paid by Mother. These payments shall be in addition to the child support award and be promptly paid directly between the parents. Any claimed health care expense for the child/ren (whether denominated as psychiatric, psychological, special education, addiction treatment or counseling in any form, and including regular medical or dental care), whether or not covered by insurance, that would result in an actual out-of-pocket expense of over $500 to the parent who did not incur or consent to the expense, shall be approved in advance, in writing, by both parents or by prior court order. Relief may be granted by the court for failure to comply under extraordinary circumstances, and the court may in its discretion apportion the incurred expense in some percentage other than that specified herein and, in so doing, may consider whether consent was unreasonably requested or withheld. 5. [ ] Work-Related Child Care Costs. The total child support amount does not include work-related child care costs. The actual net out-of-pocket costs for work-related child care shall be paid: ______% by Father and _____% by Mother. [ ] Payment shall be made directly to the child care provider by both parents according to arrangements made with the care provider. If one parent pays the child care provider any portion of the other parent’s share of costs, the non-paying parent shall reimburse the paying parent within 10 days after the paying parent provides a copy of the invoice and receipt for the payment. 6. Income Tax Exemption. The state and federal dependency tax exemption(s) for the Petitioners’ minor child/ren is/are assigned as follows: __________________________________ AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 5 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com ____________________________________________________________________________ _____________________________________________________________________________. The parent not receiving the exemption(s) shall sign the required Internal Revenue Service form(s) to release the claim to the exemption(s). 7. [ ] Name Change. The last name of Petitioners’ child/ren named above is changed to __________________________. [ ] The Bureau of Vital Statistics shall amend the birth certificate(s) of the child/ren to reflect that name. 8. Amend Birth Certificate. The Bureau of Vital Statistics shall amend the birth certificate(s) of Petitioners’ child/ren to add father’s name: (father’s legal name) _____________________________________________________. Date: ______________________________ ___________________________________ Judge Approved by Father (date) _________________________ Approved by Mother (date) _______________________ Father’s Signature Mother’s Signature AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 6 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com CLERK’S CERTIFICATE OF SERVICE I certify that a copy was served: (name all parties or their attorneys in the case, including yourself) To: ____________________________________________ (Name) ____________________________________________ (Address) ____________________________________________ (City, State and Zip) [ [ [ ] By Hand-delivery ] By Mailing ] By Fax to (number) ___________ To: ____________________________________________ (Name) ____________________________________________ (Address) ____________________________________________ (City, State and Zip) [ [ [ ] By Hand-delivery ] By Mailing ] By Fax to (number) ___________ [ [ [ ] By Hand-delivery ] By Mailing ] By Fax to (number) ___________ [ ] To: State of Idaho, Department of Health and Welfare, Division of Child Support Enforcement ____________________________________________ (Name) ____________________________________________ (Address) ____________________________________________ (City, State and Zip) Date: ____________________________ AGREED ORDER FOR CUSTODY CAO 13-4 ___________________________________ Deputy Clerk PAGE 7 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com REMOVE THIS PAGE AND Attach and Mark as “EXHIBIT A”: PARENTING PLAN Attach and Mark as “EXHIBIT B”: CHILD SUPPORT ORDER FROM OTHER CASE, IF ANY AGREED ORDER FOR CUSTODY CAO 13-4 PAGE 8 Revised 5/20/05 American LegalNet, Inc. www.USCourtForms.com