Print Form 4217 4250 4253 4284 4312 4324 4325 4386 - Continuance - Allowed Order, Plaintiff, Defendant or Witness to Appear - Allowed Produce Exhibits or other Records or Documents or Person - Allowed Strike or Withdraw Motion or Petition - Allowed Finding of Delinquency - Allowed Child Support Order Above Statutory Guidelines - Allowed Child Support Order Below Statutory Guidelines - Allowed Order to Pay Fees - Allowed 4435 4512 4567 4568 4600 4601 4604 - Clear Form Order on Motion to Provide Medical Insurance - Allowed Order Arrearage Set (amount needed) - Allowed Order For Child Support - Allowed Order Temporary Maintenance - Allowed Order Support Payments Made Direct to Petitioner Order Support Payments Made Direct to C.C.C./S.D.U. - Allowed Order Support Payments Made Direct to Respondent - Allowed (Rev. 2/08/11) CCDR 0107 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION PAGE 1 OF 6 UNIFORM ORDER FOR SUPPORT ‰ Initial Order ‰ Modification ‰ Enforcement ___________________________________________________ Petitioner / ‰ Obligee ____________________________ IV D-No. C ____________________________ ‰ Obligor v. ___________________________________________________ Respondent / ‰ Obligee Docket No. ‰ Obligor Calendar No. ____________________________ ‰ Illinois Department of Public Aid is, or has been, granted leave to intervene. Definitions: Obligor - An individual who owes a duty to make support payments pursuant to an order for support Obligee - An individual to whom a duty of support is owed or the individual’s legal representative Payor - Any payor of income to an obligor Unallocated Support - A total amount for maintenance and child support and not a specific amount for either THIS MATTER coming to be heard on Petiton for ‰ Rule and/ or ‰ Modification ‰ Support ‰ Judgment The Court Finds: The Court has jurisdiction of the parties and the subject matter and that due notice was given by ______________________ _______________________ on _______________________. ‰ a) The net income of the Obligor is $ _______________________ per _______________________. ‰ b) The amount of arrearage/judgment as of the date of this order is $ _______________________ for child support and $ $ _________________ for maintenance or unallocated support as follows: $ _____________________ to Obligee, _________________ to the Illinois Department of Public Aid, and/or $ ____________________ to the Petitioning State of ______________________________________________. ‰ c) The amount of child support cannot be expressed exclusively as a dollar amount because all or a portion of the Obligor’s net income is uncertain as to source, time of payment, or amount. ‰ d) Retroactive child support is $ ___________________ from _______________________ to _____________________. The ‰ Obligee ‰ Obligees’s Attorney ‰ Obligor ‰ Obligor’s Attorney ‰ Assistant State’s Attorney, being present ‰ This matter being an Interstate Case, ‰ Voluntary Acknowledgment of Paternity was signed on _______________________. It is Ordered: ‰ After hearing ‰ By agreement of the parties ‰ By default that: ____________________________________________________________________________________, Obligor, is to provide: ‰ MAINTENANCE Payment Amount: Current Maintenance: Arrearage Payment: (Do not complete this section if Unallocated Support is ordered.) $ _________________ $ _________________ Payments Begin: _________________________ (date) Payment Frequency: ‰ every week ‰ every other week ‰ monthly ‰ twice each month on _____________ & _____________ ‰ other ___________________________________ (date) ‰ CHILD SUPPORT OR ‰ UNALLOCATED SUPPORT Payment Amount: Payment Frequency: Current Child Support Payment or Unallocated Support Payment: $ _________________ ‰ every week Arrearage/Retroactive Payment: $ _________________ ‰ every other week Other Payment $ _________________ ‰ monthly ‰ twice each month on _____________ & _____________ Payments Begin: _________________________ (date) ‰ other ___________________________________ (date) Judgment in the amount of $ _________________ is entered against the Obligor on the arrears. Interest $ _________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 2/08/11) CCDR 0107 B PAGE 2 OF 6 ‰ PERCENTAGE AMOUNT OF CHILD SUPPORT (Complete this section only if finding (c) is checked above.) In addition to the specific dollar amount of support ordered above, current child support shall be paid in the amount of _________ % of Obligor’s __________________________________ payable _____________________________________. The Obligor is further ordered to provide income records sufficient to determine and enforce the percentage amount of child support within 7 days of receipt of income subject to this percentage assessment, to the ‰ Obligee and ‰ Clerk of the Court. ‰ ADDITIONAL CONDITIONS OR FINDINGS ‰ Child Support payment amount deviates from the amount required by statutory minimum guidelines. The amount of support that would have been required under the guidelines is $ __________________________. Reasons for deviation: _______________________________________________________________________________________ _________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ‰ Child Support is based on the needs of the child. The Child/ren covered by this Order is/are: __________________________________________________________________ Date of Birth: _________________________ __________________________________________________________________ Date of Birth: _________________________ __________________________________________________________________ Date of Birth: _________________________ __________________________________________________________________ Date of Birth: _________________________ __________________________________________________________________ Date of Birth: _________________________ __________________________________________________________________ Date of Birth: _________________________ x ‰ PAYMENT ARRANGEMENTS C H E C K O N L Y ‰ A Notice to Withhold Income shall be issued immediately and shall be served on the employer at the address listed in this Order. Payments shall be made payable to the State Disbursement Unit and sent to the State Disbursement Unit at P. O. Box 5400, Carol Stream, IL 60197-5400. Payments must include CASE NUMBER, COUNTY of the Court issuing this Order, and Obligor’s name and social security number. Any subsequent employer may be served with a Notice to Withhold Income without further order of the Court. ‰ The parties have entered into a written agreement providing for an alternative arrangement for the payment of support that is approved by the Court and attached to this Order, meeting all requirements of, and consistent with, applicable law. An income withholding notice is to be prepared and served only if the Obligor becomes delinquent in paying the order of support. Payments shall be made in accordance with the written agreement of the parties attached hereto. In the event the income withholding notice is served, payments shall be made to the State Disbursement Unit as set forth above. X ‰ In addition to and separate from amounts ordered to be paid as maintenance or child support, the Obligor shall pay a $36 per year Separate Maintenance and Child Support Collection Fee. This sum shall be paid directly to the Clerk of the Circuit Court of Cook County, at 28 N. Clark St. Room 200, Chicago, IL 60602, and not to the State Disbursement Unit. O N E 4386 (Payments must be sent to the STATE DISBURSEMENT UNIT if this box is checked.) Docket No. ______________________ IV D-No. _______________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 2/08/11) CCDR 0107 C PAGE 3 OF 6 X ‰ DELINQUENCY If the Obligor becomes delinquent in the payment of support after the entry of this Order for Support, the Obligor must pay, in addition to the current support obligation, the sum of (a) $ _________________ for delinquent child support per the payment frequency ordered above for child support, and (b) $ _________________ for delinquent maintenance or unallocated support per the payment frequency ordered above for maintenance or unallocated support, until the delinquency is paid in full. (This additional amount, the total of (a) and (b), shall not be less than 20 percent of the total of the current support amount and the amount to be paid for payment of any arrearage stated in the Order for Support.) A support obligation, or any portion of a support obligation which becomes due and remains unpaid for 30 days or more, shall accrue interest at the rate of 9% per annum. X ‰ TERMINATION This Obligation to pay child support terminates on _______________ - _______________ - _______________ unless modified by written order of the Court or unless the child will not graduate from high school until after attaining the age of 18, then the termination date shall be the earlier of the child’s high school graduation or the date on which the child will attain the age of 19. This termination date does not apply to any arrearage that may remain unpaid on that date. X ‰ ARREARS PAYMENT If any arrears or past due support is owed upon termination, the amount being paid immediately preceding termination, including any current support payment, arrearage payment and/or any delinquency, will continue to be collected as an obligation, not as current support, but as a periodic payment toward satisfaction of the unpaid support. All past due support obligations are still subject to any other special collection methods available to the Illinois Department of Public Aid (such as tax refund offsets and bank liens), as provided by law. ‰ MEDICAL INSURANCE The ‰ Obligor, ‰ Obligee, ‰ Obligor and Obligee, shall provide health insurance for the child(ren): ‰ as provided in previous order entered on ______________________________; ‰ enrolling them in any health insurance coverage available through the ‰ Obligor’s, ‰ Obligee’s, ‰ Obligor’s and Obligee’s, employment or ‰ securing a private health insurance policy, accepted by the Obligor and Obligee or approved by the Court, which names the child(ren) as beneficiary. The Obligor shall provide to the Obligee a copy of the insurance policy and the insurance card within 45 days. The employer or labor union or trade union shall disclose information concerning dependent coverage plans whether or not a court order for medical support has been entered. 750 ILCS 5/505.2. ‰ The Obligor is liable for ________ % of medical expenses incurred by the minor child(ren) and not covered by insurance. 4284 ‰ The issue of medical insurance is withdrawn. It is further ordered that (except when the Court finds that the physical, mental or emotional health of a party or that of a minor child, or both, would be seriously endangered by disclosure of the party’s address:) The Obligor shall give written notice to the Clerk of the Court, and if a party is receiving child and spouse services under Article X of the Illinois Public Aid Code, to the Department of Public Aid, within 7 days, of: • any new residential, mailing address or telephone number; • the name, address and phone number of any new employer, and; • the policy name and identifying number(s) of health insurance coverage available. The Obligor shall submit a written report of termination of employment and of new employment, including name and address of the new employer, to the Clerk of the Court and the Obligee within 10 days. Obligor and Obligee shall advise each other of a change of residence within 5 days except when the Court finds that the physical, mental or emotional health of a party or that of a minor child, or both, would be seriously endangered by disclosure of the party’s address. An Obligee receiving payments through income withholding shall notify the Clerk of the Court and the State Disbursement Unit within 7 days, of change in residence. The Obligor and Obligee shall report to the Clerk of the Court any change of information included in the Child Support Data Sheet (Exhibit 1) within 5 business days of such a change. ‰ UNEMPLOYMENT: ‰ Respondent is unemployed and is ordered to seek employment. The Respondent must report periodically to the court with a diary listing the name, address, telephone number and contact person of each employer with which he or she has sought employment. Docket No. ______________________ IV D-No. _______________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 2/08/11) CCDR 0107 D PAGE 4 OF 6 ‰ Respondent is ordered to report to the Department of Employment Security for job search services or to complete an application with the local Job Training Partnership Act provider for participation in job search, training or work programs. ‰ Respondent is unemployed and is ordered to put forth a diligent effort to obtain employment and to cooperate with all instructions of the Illinois Department of Public Aid. The Respondent is ordered to report immediately to the Illinois Department of Public Aid’s Non-Custodial Parent Services Unit, R. J. Daley Center, 50 W. Washington St., CL-24, Chicago, Illinois for assessment and assignment into the court monitored Job Search program or Earnfare program. Upon finding employment, the Respondent shall notify IDPA in writing at R. J. Daley Center, 50 W. Washington St., CL-24, Chicago, Illinois 60602, within seven days. The Respondent must submit the name and address of the employer, the start date, and the rate of pay to the IDPA Non-Custodial Parent Services Unit. The Respondent’s failure to comply with the requirements of this order may result in the State’s Attorney seeking a contempt of court order. (Note: Earnfare requires a $50.00 minimum support order.) ‰ GENETIC TEST REIMBURSEMENT: Obligor shall pay $ ___________________ to the Illinois Department of Public Aid (IDPA) for a genetic test reimbursement. Payments must be made in lump sum or installments by personal check or money order payable to Illinois Department of Public Aid and either mailed to: Illinois Department of Public Aid, Title IV-D Accounting Unit, P.O. Box 19138, Springfield, IL 62705-9138, or conveyed as otherwise directed by the Court. Payment must include IV-D number as shown on this Order. This Order does not preclude the Illinois Department of Public Aid from collecting any arrearage established by or which may accrue under this Order for Support by use of the offset provisions of Section 6402(c) of the Internal Revenue Code of 1954, and 15 ILCS 405/10.05(a) as amended. Such arreage shall be considered as “past due” or “due and payable” within the meaning of said statutory provisions. This order does not preclude the placing of a lien on real and personal assets or initiating a proceeding for garnishment, attachment of sequestration pursuant to law and the Code of Civil Procedure. This order of support supercedes any and all prior orders of support under this case number. ‰ Other: ______________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ‰ This cause is continued for at ______________________ m. ___________________________________ to ___________________________________, ‰ without further notice ‰ without further notice to Petitioner ‰ without further notice to Respondent. FAILURE TO APPEAR MAY RESULT IN ENTRY OF A DEFAULT JUDGMENT. ‰ FOR EXPEDITED CHILD SUPPORT CASES ONLY: NOTICE OF RIGHT TO REQUEST A JUDICIAL HEARING: You have a right to request a Judicial Hearing. If either party does not agree to the recommended Order or any part thereof, this case will be transferred for an immediate Judicial Hearing. Docket No. ______________________ IV D-No. _______________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 2/08/11) CCDR 0107 E PAGE 5 OF 6 This order may be vacated or amended within 30 days of its entry. This order is not valid until signed by a judge. So recommended to this Court by the Hearing Officer this ____________ day of ___________________________, _________ ________________________________________________ Hearing Officer’s Signature ________________________________________________ ________________________________________________ Petitioner/ Obligee’s Signature Respondent/ Obligor’s Signature ________________________________________________ ________________________________________________ Petitioner/ Obligee’s Attorney’s Signature Respondent/ Obligor’s Attorney’s Signature The support obligation herein required under this order, or any portion of the obligation, which becomes due and remains unpaid for 30 days or more shall accrue simple interest at the rate of 9% per anum. FAILURE TO OBEY ANY OF THE PROVISIONS OF THIS ORDER MAY RESULT IN A FINDING OF CONTEMPT OF COURT. _________________________________________ Date ________________________________________________ Judge Prepared by: Atty. Code No.: ___________________ Name: ______________________________________________ Atty. for: ____________________________________________ Address: ____________________________________________ City/State/Zip: ________________________________________ Telephone: __________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Judge’s No. (Rev. 2/08/11) CCDR 0107 F PAGE 6 OF 6 _____________________________________________________ Case No. _____________________________________ Plaintiff/Petitioner County: _____________________________________ v. Date: _______________________________________ _____________________________________________________ Defendant/Respondent CHILD SUPPORT DATA SHEET OBLIGOR INFORMATION OBLIGEE INFORMATION Last Name: __________________________________________ Last Name:________________________________________ First Name: _______________________ Middle In: ________ First Name: _____________________ Middle In: ________ Complete Residential Address: Complete Residential Address: Complete Mailing Address (If other than above): Complete Mailing Address (If other than above): Date of Birth: Date of Birth: Driver’s License No.: Driver’s License No.: Home Phone Number: Home Phone Number: Employer(s) Name/Company: Employer(s) Name/Company: Employer(s) Address: Employer(s) Address: Employer(s) ID Number: Employer(s) ID Number: Work Phone Number ( ) Work Phone Number ( ) CHILD/CHILDREN INFORMATION LAST FIRST MIDDLE INITIAL DATE OF BIRTH 1. __________________________________________________________________________________________________ 2. __________________________________________________________________________________________________ 3. __________________________________________________________________________________________________ 4. __________________________________________________________________________________________________ 5. __________________________________________________________________________________________________ (If more space is needed, attach an additional sheet.) * If Obligor is not a US citizen, so indicate and provide the Obligor’s alien registration number, passport number and home country’s social security or national health number. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS