CHILD SUPPORT ORDER Page 1 of 4 UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT 3401-1 (Rev 05/16/2011) STATE OF ILLINOIS IN RE COUNTY OF DU PAGE THE MARRIAGE OF CIVIL UNION OF PARENTAGE CASE NUMBER vs PETITIONER Support Account Number RESPONDENT HFS Number File Stamp Here Illinois Health Care and Family Services (HFS) is or has been granted leave to intervene. ORDER FOR SUPPORT Original Order DEFINITIONS: OBLIGOR: OBLIGEE: PAYOR: An individual who owes a duty to make support payments pursuant to an order of support. An individual to whom a duty of support is owed or the individual's legal representative. Any payor of income to an obligor. Amended Order 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 on the date of this order is $ per 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 HEREBY ORDERED THAT: the OBLIGOR, is to provide: CHILD SUPPORT MAINTENANCE PERCENTAGE AMOUNT OF CHILD SUPPORT UNALLOCATED SUPPORT PAYMENT ARRANGEMENTS (CHECK ONE ONLY) A Notice to Withhold Income shall be issued 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. Payments shall be made payable to STATE DISBURSEMENT UNIT and sent to P.O. Box 5400, Carol Stream, IL. 60197-5400. Payments must include CASE NUMBER and DuPage County which is the Issuing Court of this Order along with Obligor's name and social security number. DISTRIBUTION: Original - Circuit Clerk Copies - Plaintiff - Respondent - Attorneys CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 American LegalNet, Inc. www.FormsWorkFlow.com CHILD SUPPORT ORDER Page 2 of 4 3401-2 (Rev 2/12) PAYMENT ARRANGEMENTS (continued) CASE # 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 with payments through the SDU is to be prepared by the obligee or the obligee's legal representative 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, 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 $36.00 for the administration of this account as set forth in 705 ILCS 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 made payable to the Clerk of the Circuit Court. The payment shall be clearly marked "Annual Fee for YEAR " and sent to the Clerk of the Circuit Court, P.O. Box 707, Wheaton, IL 60187-0735. PAYMENT SCHEDULES The Child Support payment terminates on unless modified by a written order of court. Insert a date above no earlier than the date the youngest child reaches the age of 18. This termination date does not apply to any arrearage that may remain unpaid on that date. PAYMENT AMOUNT Current Payment $ PAYMENTS TO BEGIN ON: Date MANDATORY END DATE REQUIRED BEGIN BALANCE IF APPLICABLE AS OF DATE IF APPLICABLE Arrearage Payment $ DESCRIPTION MAINTENANCE UNALLOCATED SUPPORT CHILD SUPPORT DAY CARE % AMOUNT OF CHILD SUPPORT MEDICAL INSURANCE ARREARAGE IS SET AT * PAYMENT IF FOR OTHER SPECIFY TOTAL AMOUNT DUE PER PAYMENT AMOUNT FREQUENCY START DATE PAYMENT MUST BE IN U. S. DOLLARS AND CENTS DELINQUENCY "DELINQUENCY" PAYMENT AMOUNT MUST BE INCLUDED AND SHALL NOT BE LESS THAN 20% OF CURRENT SUPPORT AND ARREARAGE PAYMENTS COMBINED CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 American LegalNet, Inc. www.FormsWorkFlow.com CHILD SUPPORT ORDER Page 3 of 4 3401-3 ( Rev 2/12) DELINQUENCY CASE # 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 unallocated 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 obligation, or any portion of a support obligation which becomes due and remains unpaid as of the end of each month, excluding the child support that was due for that month to the extent that it was not paid in that month, shall accrue simple interest as set forth in Section 12-109 of the code of civil procedure. Interest due and owing as a result of unpaid support will be set forth under "Additional Conditions or Findings" in this Order for Support or in a separate Order. EMPLOYER: YOU DO NOT HAVE TO VARY YOUR PAY CYCLE TO BE IN COMPLIANCE WITH THE SUPPORT ORDER. IF YOUR PAY CYCLE DOES NOT MATCH THE ORDERED SUPPORT FREQUENCIES, USE THE FOLLOWING TO DETERMINE HOW MUCH TO WITHHOLD. $ $ weekly pay period (52 or 53) times per year bi-weekly pay period (26) times per year $ $ semi-monthly pay period (24) times per year monthly pay period (12) times per year COMPLETE THIS SECTION ONLY IF PAYMENTS ARE TO BE MADE TO A PARTY OTHER THAN THE OBLIGEE SUCH AS PAYMENTS TO: HFS, INTERVENOR, GUARDIAN, ESCROW, ETC. NAME/AGENCY ADDRESS REFERENCE NO. ELECTRONIC FUNDS TRANSFER FIPS NUMBER FAX-AREA CODE AND PHONE NO. PHONE/AREA CODE AND PHONE NO. INTERNET ADDRESS INSURANCE The Obligor Obligee Obligor and Obligee shall provide health insurance for the child/children either by enrolling them in the health insurance coverage through Obligee's Obligor's and Obligee's Obligor's employment, or through a labor or trade union, or 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. Both the obligor and obligee shall be provided with a copy of the insurance policy, the insurance card, the name of the health insurance provided and the number of the insurance