IN THE CIRCUIT COURT OF NINTH JUDICIAL COUNTY , ILLINOIS UNIFORM ORDER FOR SUPPORT [ ] Initial Order [ ] Modification ________________________________________ ) PetitionerlPlaintiff ) ) vs. ) ) ________________________________________ ) RespondentlDefendant Court Case No. _______________________ Illinois Dept. of Healthcare & Family Services is, or has been, granted leave to intervene HFS. 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: Payment Frequency: Current Maintenance or Unallocated Support Payment: $ _________ Arrearage Payment $ __________ [ [ [ [ [ [ ] 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 I of 4 American LegalNet, Inc. www.FormsWorkFlow.com Revised 4l28l06 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 Check Only One [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 in this Order. Payments shall be made payable to the State Disbursement Unit and sent to the State Disbursement Unit at _____________________________________________________. 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. Payments shall be made payable to and sent t ________________________ and sent to THE CLERK OF THE CIRCUIT COURT at . ______________________________________. Payments must include CASE NUMBER and COUNTY of the Court issuing this Order. 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 _______________________________________ County at _______________ _____________________________________________________________ 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 I2-I09 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 I2-I09 of the Code of Civil Procedure. Form approved by Conference of Chief Circuit Judges Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Revised 4l28l06 [X] Case No. ________________ 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 I8 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 childlchildren covered by this order islare: [ ] 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 benefitslcoverage 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 Public Aid Code, to the Department of Healthcare & Family Services, 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 I) 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 American LegalNet, Inc. www.FormsWorkFlow.com Revised 4l28l06 CASE NO. ______________ If there is an unpaid arrearage or delinquency equal to at least one month�s child support oblication on the termination date, then the periodic amount required to be paid for current child support prior to the termination date shall automatically continue to be an obligation toward satisfaction of the unpaid arrearage or delinquency until paid in full. This payment shall be in addition to any periodic payment required for the satisfaction of the arrearage or delinquency which payments shall continue until such amounts are paid in full. Other: The �Child Support Data Sheet� attached hereto, as Exhibit I, is a part of this Order. It is ordered the Clerk of the Court impound Exhibit I 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 American LegalNet, Inc. www.FormsWorkFlow.com Revised 4l28l06 ____________________________ CASE NO. ______________ PLAINTIFF/PETITIONER COUNTY_______________ vs. ___________________________ DATE__________________ CHILD SUPPORT DATA SHEET DEFENDANT/RESPONDENT OBLIGOR INFORM ATION OBLIGEE INFORM ATION 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.: *Social Security No.: *Social Security 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 SOCIAL SECURITY NUMBER 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. Form Approved by Conference of Chief Circuit Judges Exhibit 1 American LegalNet, Inc. www.FormsWorkFlow.com Revised 4/28/06