STATE OF MAINE SUPERIOR COURT __________________________, ss Docket No.___________________ DISTRICT COURT Location______________________ Docket No.____________________ Plaintiff v. CHILD SUPPORT ORDER Defendant This Child Support Order is made a part of the Divorce Judgment Protection from Abuse Order Parental Rights and Responsibilities Judgment Paternity Judgment Case Management Order Other ____________________________ of this date dated____________________________ . Pursuant to 19-A M.R.S.A. §2006, the court has made certain findings of fact concerning the current parental support obligation as computed under the presumptive application of the guidelines. Those findings are contained within the child support worksheet which is attached and incorporated. _____________________________________ is ordered to pay to ______________________________ Name of obligor Name of obligee the sum of $______________ per week toward the support of: Child’s Name Date of Birth Child’s Name Date of Birth The child support payments are to start __________________________________________. If a child receives public assistance, the child support payments for that child shall be made to the State of Maine Department of Health & Human Services. The Court finds that the child(ren) currently receive(s) dependent benefits as a result of the obligor's disability. In any month that the benefits received by the child(ren) meet or exceed the total monthly support obligation, the obligor shall receive a credit for the total amount of support due. To the extent that the monthly benefits received by the child(ren) do not satisfy the obligor's monthly support obligation, the obligor shall pay the monthly support obligation minus the credits received by the child(ren). The obligor shall not be given credit toward past or future obligations for benefits which exceed the current monthly support obligation. The child support obligation shall remain in effect until ____________________________ (further order or until expiration of any underlying Protection from Abuse Order, whichever occurs first). The child support obligation shall continue for each child until that child reaches the age of 18; provided, however, that if the child has not graduated, withdrawn, or been expelled from secondary school as defined in Title 20-A, the child support shall continue until the child graduates or reaches the age of 19, whichever occurs first. ____________________________________ shall maintain health insurance for the benefit of the minor child(ren) if it is available at a reasonable cost, which means health insurance that is employment-related or other group health insurance. Proof of such insurance must be furnished to the other party within 15 days. If the child(ren) is (are) recipients of public assistance, proof of such insurance shall be provided to the Department of Health & Human Services within 15 days. Any uninsured medical and dental expenses of the child(ren), in excess of $250 per calendar year, shall be paid in the following manner: __________% by the obligor and __________% by the obligee. The first $250 of annual uninsured medical expenses shall be paid by the obligee. The child support obligation is based on the fact the parents are providing substantially equal care for their child(ren). Day care costs, health insurance premiums, and uninsured medical expenses shall be shared as follows: % to be paid by the higher income parent and % to be paid by the lower income parent. The child support amount set forth above has been adjusted to reflect each party’s proportionate share of these costs. Each party’s proportionate share will be paid as follows: FM-132, Rev. 09/05 American LegalNet, Inc. www.USCourtForms.com If the Maine Department of Health & Human Services provides support enforcement services and/or if the obligor is required to pay child support to the Maine Department of Health & Human Services, the obligor shall notify the Department within 15 days of the date of this Order of the following: 1. The obligor's current address; 2. The name and address of the obligor's current employer, and 3. Whether the obligor has access to health insurance at a reasonable cost, and, if so, the health insurance policy information. Within 15 days of any change in the obligor's current address, any change in the name or address of the obligor's current employer, or any change in the health insurance policy information, the obligor shall notify the Department of the change. Failure to report a change of address or employer to the Department within 15 days of such change is a civil violation for which a forfeiture not to exceed $200 may be adjudged for each violation. Any party to this action may ask the court to review the amount of child support and if appropriate, to modify it in accordance with the state's child support guidelines. To start this process, a party must file with the court a Motion to Modify. If it has been less than 3 years since the child support order was issued or modified, the party must prove a substantial change in circumstances. There is (are) _________ child(ren) who is (are) 10 or 11 years of age. Beginning _______________ when ___________________________ reaches the age of 12 years, the child support will be $ per week. Beginning _________________________ when _______________________________ child support will be $____________________ per week. reaches the age of 12 years, the All of the minor children are age 12 or older. As long as there are ____________ children entitled to parental support, that sum is $________________ per week. As long as there are _____________ children entitled to parental support, that sum is $________________ per week. When only one child is entitled to parental support, the sum is $___________________ per week. The amount(s) set forth above for child support constitute(s) a deviation from the presumptive amount required by the child support guidelines. In this case the court finds that a child support order based on the guidelines would be inequitable or unjust for the following reasons: (Set forth the reasons for the deviation.) The Immediate Income Withholding Order of this date attached hereto is incorporated by reference. No Immediate Income Withholding Order shall issue because: The court finds there is good cause not to issue such an order for the following reasons: The parties have submitted and the court has approved a written agreement providing for an alternative arrangement. The clerk is directed to make the following entry in the civil docket pursuant to M.R.Civ.P. 79(a). "Child Support Order filed. __________________________________ ordered to pay child support of $___________________ per week. This Order is incorporated into the docket by reference at the specific direction of the court." Date: _______________________ ____________________________________ Judge / Justice / Magistrate A True Copy. Attest ___________________________________________ Clerk Important Notice to the Parties Any party who wishes to appeal a Magistrate’s final order shall file an objection to the final order in the District Court within 21 days of the entry of that order. The court clerk's office has a form available for this purpose. If no objection is filed, the parties are deemed to have waived their right to object and t o appeal, and the Magistrate's final order shall become the judgment of the court and have the same effect a s any final judgment signed by a District Court judge. No appeal may be taken from a judgment entered without objection to the final order of a Magistrate. An appeal from a judgment entered after objection shall be taken in accordance with the Maine Rules of Appellate Procedure. Any party who wishes to appeal a final order of a judge or justice shall file a Notice of Appeal within 2 1 days. FVI FM-132, Rev. 09/05, pg. 2 American LegalNet, Inc. www.USCourtForms.com