IN THE CIRCUIT COURT OF THE 14TH JUDICIAL CIRCUIT ROCK ISLAND COUNTY, ILLINOIS UNIFORM ORDER FOR SUPPORT [ ] INITIAL ORDER [ ] MODIFICATION _________________________________ Petitioner/Plaintiff Court Case No.____________________ Illinois Dept of Public Aid is, or has been Granted leave to intervene Vs ________________________________________ Respondent/Defendant IDPA. 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 if 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 Payment Amount: Current Maintenance or Unallocated Support Payment: $_______________ Arrearage Payment $_______________ [ ] UNALLOCATED SUPPORT 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 5/2006 American LegalNet, Inc. www.USCourtForms.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. [ ] PAYMENT ARRANGEMENTS (Check only one) (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 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. [ ] 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 the 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 9%, 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 5/2006 American LegalNet, Inc. www.USCourtForms.com Case No. ________________________ [ ] TEMINATION 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, [ ] oblige, [ ] obligor and oblige, 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 oblige 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 Ilinois 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 indentifying 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 oblige 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 oblige 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 oblige shall report to the Clerk of the Court and 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 is $____________________. Reasons for deviation:_____________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Form approved by Conference of Chief Circuit Judges Page 3 of 4 Revised 5/2006 American LegalNet, Inc. www.USCourtForms.com Case No. ___________________ Other:______________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ The “Child Support Data Sheet” attached hereto, as Exhibit 1, is a part of the 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 5/2006 American LegalNet, Inc. www.USCourtForms.com _________________________________________ PLAINTIFF/PETITIONER CASE NO.______________________ Vs COUNTY______________________ _________________________________________ DEFENDANT/RESPONDENT DATE_________________________ CHILD SUPPORT DATA SHEET OBLIGOR INFORMATION OBLIGEE INFORMATION Last name Last name: First name: MI Complete Residential Address First name Complete Residential Address Complete Mailing Adrress (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.: Hone Phone Number:( ) Home Phone Number( MI ) 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 MI DOB SOCIAL SECURITY NO 1. 2. 3. 4. 5. *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 Revised 5/2006 American LegalNet, Inc. www.USCourtForms.com