IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS UNIFORM ORDER FOR SUPPORT [ ] Initial Order [ ] Modification _______________________________________) Petitioner/Plaintiff ) ) vs. ) ) _______________________________________) Respondent/Defendant Court Case No.________________________ Illinois Dept. of Healthcare and Family Services is, or has been, granted leave to intervene H.F.S. No. ___________________________ 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. The Court finds: a) The net income of the obligor as of the date of this order is $_________________ per __________. b) The amount of arrearage as of the date of this order is $________ for child support and $________ for maintenance or unallocated support. 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. It is ordered that ________________________________, Obligor, is to provide: [ ] MAINTENANCE OR [ ] UNALLOCATED SUPPORT Payment Amount: Current Maintenance or Unallocated Support Payment: $__________ Arrearage Payment $__________ Payment Frequency: [ ] every week [ ] every other week [ ] monthly [ ] twice each month on ________ & ________ (date) [ ] every year [ ] other Payments Begin: __________________ (date) [ ] CHILD SUPPORT (Do not complete this section if Unallocated Support is ordered.) Payment Amount Current Child Support Payment: $__________ Arrearage Payment: $__________ Payments Begin: ____________(date) Form approved by Conference of Chief Circuit Judges Payment Frequency: [ ] every week [ ] every other week [ ] monthly [ ] twice each month on ________ & ________ (date) [ ] every year [ ] other Page 1 of 4 Revised 1/20/06 White – Clerk; Yellow – Petitioner; Pink - Defendant American LegalNet, Inc. www.FormsWorkflow.com Case No._______________ [ ] 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. [ X ] PAYMENT ARRANGEMENTS (Payments must be sent to the STATE DISBURSEMENT UNIT if this box is checked.) A Notice to Withhold Income shall issue 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 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 for 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. State law does not require payment to the State Disbursement Unit and the parties have not entered into a written agreement as provided above. 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 DeKalb County at 133 W. State Street, Sycamore, Illinois, 60178 and not to the State Disbursement Unit. [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 child support per the payment frequency ordered above for child support, and (b) $___________ for 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 periodically 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 ________, as set forth in Section 12-109 of the Code of Civil Procedure or as otherwise provided by law. Any portion of a support obligation that remains unpaid at the end of a month, excluding the support that became due for that month, shall accrue interest as provided in Section 12-109 of the Code of Civil Procedure. Form approved by Conference of Chief Circuit Judges Page 2 of 4 Revised 1/20/06 White – Clerk; Yellow – Petitioner; Pink - Defendant American LegalNet, Inc. www.FormsWorkflow.com Case No._______________ [X] TERMINATION This obligation to pay child support terminates on _____-_____-_____ unless modified by written order of the Court. (Insert a date no earlier than the date that the youngest child reaches the age of 18 or is expected to graduate from high school, whichever comes later.) This termination date does not apply to any arrearage that may remain unpaid on that date. The child/children covered by this order is/are: __________________________________________________________________________________________________ __________________________________________________________________________________________________ [ ] INSURANCE The [ ] obligor, [ ] obligee, [ ] obligor and obligee, shall provide health insurance for the child(ren) either by [ ] 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. Both the obligor and the obligee shall be provided a copy of the insurance policy and the insurance card. The name of the health insurance provider and the number of the insurance policy regarding dependent benefits/coverage on the date of this order as follows: Name of Health Insurance Provider(s): Policy No.(s): _________________________________________________ _________________________________________________ ____________________________________ ____________________________________ It is further ordered that: 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 Department of Healthcare and Family Service Code, to the Illinois Department of Healthcare and Family Service, 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 a 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 change. [ ] 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:_________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Form approved by Conference of Chief Circuit Judges Page 3 of 4 Revised 1/20/06 White – Clerk; Yellow – Petitioner; Pink - Defendant American LegalNet, Inc. www.FormsWorkflow.com Case No._______________ Other: _______________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ The “Child Support Data Sheet” attached hereto, as Exhibit 1, is a part of this Order. It is ordered the Clerk of the Court impound Exhibit 1 until further order of this Court. FAILURE TO OBEY ANY OF THE PROVISIONS OF THIS ORDER MAY RESULT IN A FINDING OF CONTEMPT OF COURT ____________________ Date __________________________________________________________ Judge Prepared by: __________________________ Attorney for: __________________________ Address: __________________________ _______________________________________ Telephone: __________________________ Attorney No.: __________________________ Form approved by Conference of Chief Circuit Judges Page 4 of 4 Revised 1/20/06 White – Clerk; Yellow – Petitioner; Pink - Defendant American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER FORM Page 1 of 3 (REV 6/02) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DEKALB IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT Case Number Petitioner and Respondent FILE STAMP HERE I.D.P.A. Number I.D.P.A. is or has been granted leave to intervene ORDER FOR SUPPORT ORIGINAL ORDER AMENDED ORDER DEFINITIONS: OBLIGOR: An individual who owes a duty to make support payments pursuant to an order of support. OBLIGEE: An individual to whom a duty of support is owed or the individual's legal representative. Any payor of income to an obligor. PAYOR: UNALLOCATED SUPPORT: A total amount for maintenance and child support and not a specific amount for either. THE COURT FINDS: The net income of the obligor as of (date)_______________________ for this order is $_________________________ per __________________________. The amount of arrearage as of (date) ______________________ for this order is $___________________ for child support and $ _________________ for maintenance or unallocated support. ______________________________________________________________________________________________________ IT IS HEREBY ORDERED THAT: the OBLIGOR is to provide: CHILD SUPPORT PAYMENT AMOUNT MAINTENANCE UNALLOCATED SUPPORT PAYMENT FREQUENCY Every week (52 or 53 times a year) Support Payment $___________________ Arrearage Payment $______________________ Every other week (26 times a year) Twice a month on _____ & _____ (24 times a year) Monthly (12 times a year) Day Care $______________________ Insurance $______________________ Other $______________________ Other _______________________________________ ____________________________________________ PAYMENTS TO BEGIN ON: (Date) MAUREEN A. JOSH, CLERK OF THE DEKALB COUNTY CIRCUIT COURT SYCAMORE, ILLINOIS 60178 White- Clerk Yellow-Petitioner Pink-Defendant American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER FORM Page 2 of 3 PAYMENT ARRANGEMENTS (REV 6/02) CASE # _______________ (PAYMENTS MUST BE SENT TO THE STATE DISBURSEMENT UNIT IF THIS BOX IS CHECKED) A Notice to Withhold Income shall issue immediately and shall be served on the employer at the address listed in this Order. Any subsequent employer may be served with a Notice to Withhold Income without further order of the Court. OR The parties have entered into a written agreement providing for an alternate 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 for support.) OR State law does not require payment to the State Disbursement Unit and the parties have not entered into a written agreement as provided above. ALL SUPPORT PAYMENTS ARE TO BE MADE: (This box must be checked if a Notice to Withhold Income is issued immediately) PAYABLE to the STATE DISBURSEMENT UNIT and sent to P.O. BOX 8000 WHEATON, IL 60189-8000. Payments must include CASE NUMBER, DeKalb County, and the obligor's name and social security number. OR PAYABLE in accordance with the written agreement of the parties attached hereto. OR PAYABLE to The Clerk of the Circuit Court and mailed to 133 W. State St., Sycamore, IL 60178. Payment must include CASE NUMBER, DeKalb County, and the obligor's name and social security number. AND The Obligor shall, in addition to and separate from the amounts ordered to be paid as maintenance or child support, pay an annual fee of $36 for the administration of this account as set forth in 705 lLCS 105/27.2 (bb4). This fee shall be due and payable upon receipt of an invoice from the Circuit Court Clerk. Payment of this invoice shall be sent directly to The DeKalb County Clerk of the Circuit Court and mailed to 133 W. State St. Sycamore, IL 60178. 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 $______________________for child support and/or maintenance or unal1ocated support per the payment frequency ordered above until the delinquency is paid in full. This additional amount shall not be less than twenty percent (20%) of the total of the current support amount and the amount to be paid periodically for payment of any arrearage stated in the Order for Support a support obligator, 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 nine percent (9%) per annum Interest due and owing as a result of unpaid Support will be set forth under “Additional Conditions or Findings" in this Order for Support in a separate Order. This obligation to pay child support terminates on_______________ unless modified by written order of the Court. (Insert a date no earlier than the date that the youngest child reaches the age of 18 or is expected to graduate from high school, whichever comes later.) This termination does not apply to my arrearage that may remain unpaid on that date. MAUREEN A. JOSH, CLERK OF THE DEKALB COUNTY CIRCUIT CLERK SYCAMORE, ILLINOIS 60178 White- Clerk Yellow-Petitioner Pink-Defendant American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER FORM Page 3 of 3 (Rev 6/02) INSURANCE The Obligor Obligee CASE#___________________ Obligor and Obligee, shall provide health insurance for the child/children either by enrolling the child/children in any health insurance coverage through the employment, or through a labor or trade union, or Obligor's Obligee's Obligor and Obligee's securing a private health insurance policy, accepted by the obligor and obligee or as approved by the Court, which names the child/children as beneficiary. The obligor shall provide the obligee with a copy of the insurance policy, the insurance card, the name of the health insurance provided and the number of the insurance policy regarding dependent benefits/coverage within 30 days of this of this order. If the Illinois Department of Public Aid is a party to this case, the obligor shall provide written proof to the DeKalb CountyState’s Attorney’s Office within 30 days that the required insurance has been obtained. Name of Health Insurance Provider(s) ______________________________ ______________________________ Policy Number(s) ______________ ______________ Telephone Number(s) __________________ __________________ It is further ordered that: The Obligor must notify the Court (Clerk of the Circuit Court), the other party (obligee) and if a party is receiving child or spouse support under Article X of the Illinois Public Aid Code, in writing, within five (5) days: If the Obligor's employment is terminated. The name, address and phone number of any new employer. The policy name and identifying number(s) of health insurance coverage and other information concerning benefits provided by the new employer. It is further ordered that both the obligor and obligee shall notify the Clerk of the DeKalb County Circuit Court, 133 W. State St., Sycamore, IL 60178 in writing of any change in their name, residence address, phone number and place of employment and any change in health insurance coverage within five (5) days. ADDITIONAL CONDITION 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 $_____________________ Reason for deviation: _________________________________________________________________________ __________________________________________________________________________________________________________ OTHER: __________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ DATE: ENTER: FAILURE TO OBEY ANY 0F THE PROVISIONS OF THIS ORDER MAY RESULT IN A FINDING OF CONTEMPT OF COURT Name: _____________________________________ DeKalb Attorney No.: _________________________ Attorney For: ________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Reviewed and approved as to form ________________________________________ Deputy Circuit Clerk DeKalb County Circuit Court Clerk Child Support Division Date: ____________________________________ Telephone: __________________________________ MAUREEN A. JOSH, CLERK OF THE DEKALB COUNTY CIRCUIT CLERK White- Clerk SYCAMORE, ILLINOIS 60178 Yellow-Petitioner Pink-Defendant American LegalNet, Inc. www.FormsWorkflow.com Child Support Data Sheet STATE OF ILLINOIS (Rev. 6/02) UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT __________________________________________ Court Case No. COUNTY OF DEKALB _______________________________________________ IDPA Case No. CHILD SUPPORT DATA SHEET OBLIGOR INFORMATION Last Name First Name OBLIGEE INFORMATION Middle Last Name First Name Middle 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. State (if other than Illinois) Driver License No. ’s State (if other than Illinois) Social Security No. or Alien Registration No. Social Security No. or Alien Registration No. Home Telephone / Area Code and Number Home Telephone / Area Code and Number Employer(s) Name/Company Employer(s) Name/Company Employer(s) Address Employer(s) Address Employer(s) FEIN Number Employer(s) FEIN Number Work Telephone / Area Code and Number Work Telephone / Area Code and Number CHILD/CHILDREN INFORMATION (On whose behalf the child support is to be paid under the terms of this order) LAST NAME FIRST NAME M.I. DATE OF BIRTH SOCIAL SECURITY NO. MAUREEN A. JOSH, CLERK OF THE DEKALB COUNTY CIRCUIT COURT SYCAMORE, IL 60178 White- Clerk Yellow-Petitioner Pink-Defendant American LegalNet, Inc. www.FormsWorkflow.com