Approved, SCAO Original - Court 1st copy - Plaintiff 2nd copy - Defendant 3rd copy - Friend of the court STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address UNIFORM CHILD SUPPORT ORDER, NO FRIEND OF COURT SERVICES (PAGE 1) EX PARTE TEMPORARY MODIFICATION FINAL CASE NO. Court telephone no. Plaintiff's name, address, and telephone no. Defendant's name, address, and telephone no. v Plaintiff's attorney name, bar no., address, and telephone no. Defendant's attorney name, bar no., address, and telephone no. Plaintiff's source of income name, address, and telephone no. Defendant's source of income name, address, and telephone no. This order is entered after hearing. on stipulation/consent of the parties. . An order exempting this case from friend of the court services was entered on (NOTE: If there is no order exempting this case from friend of the court services, form FOC 10/52 must be used.) IT IS ORDERED, UNLESS OTHERWISE ORDERED in item 11: Standard provisions have been modified (see item 11). 1. The support obligation for a child continues through the end of the month of the later: 1) the child's 18th birthday, or 2) the last day of regularly attending high school full time with the reasonable expectation of graduating, as long as the child is residing full time with the recipient of support or at an institution, but under no circumstances shall the support obligation continue after the month that the child reaches age 19 1/2. Child care for a child continues through August 31 following that child's 12th birthday. The parties must notify each other of changes in child-care expenses and must additionally notify the friend of the court if the change ends those expenses. 2. Child Support. The payer is ordered to pay a monthly child-support obligation as follows. Payer: Payee: Support effective date: Children's names, birth dates, and annual overnights with payer: Children supported: 1 child 2 children 3 children 4 children Base support: (includes support plus or minus premium adjustment for health-care insurance) Support: $ $ $ $ Premium adjust. $ $ $ $ Subtotal: $ $ $ $ Ordinary medical: $ $ $ $ Child care: $ $ $ $ Other: $ $ $ $ SS benefit credit: $ $ $ $ Total: $ $ $ $ Support was reduced because payer's income was reduced. 5 or more children $ $ $ $ $ $ $ $ (See page 2 for the remainder of the order.) MCL 552.14, MCL 552.517, MCL 552.517b(3), MCR 3.211 American LegalNet, Inc. www.FormsWorkFlow.com FOC 10a / 52a (3/12) UNIFORM CHILD SUPPORT ORDER, NO FRIEND OF COURT SERVICES, PAGE 1 Approved, SCAO Original - Court 1st copy - Plaintiff 2nd copy - Defendant 3rd copy - Friend of the court STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address UNIFORM CHILD SUPPORT ORDER, NO FRIEND OF COURT SERVICES (PAGE 2) EX PARTE TEMPORARY MODIFICATION FINAL CASE NO. Court telephone no. Plaintiff's name v Defendant's name 3. Insurance. For the benefit of the children, the plaintiff defendant shall maintain health-care coverage through an insurer (as defined in MCL 552.602) that includes payment for hospital, dental, optical, and other health-care expenses when that coverage is available at a reasonable cost, including coverage available as a benefit of employment or under an individual policy up to a maximum of $ for plaintiff. up to a maximum of $ for defendant. not to exceed 5% of the plaintiff's/defendant's gross income. 4. Uninsured Health-Care Expenses. All uninsured health-care expenses exceeding the annual ordinary medical amount will be paid % by the plaintiff and % by the defendant. Uninsured expenses exceeding the annual ordinary medical amount for the year they are incurred that are not paid within 28 days of a written payment request may be enforced by filing a motion with the court. The annual ordinary medical amount is . 5.Qualified Medical Support Order. This order is a qualified medical support order with immediate effect pursuant to 29 USC 1169. Further details, as prescribed by 29 USC 1169(a)(3), are stated in item 11. 6. Retroactive Modification and Liens for Unpaid Support. Except as provided by MCL 552.603, support is a judgment the date it is due and is not modifiable retroactively. Unpaid support is a lien by operation of law and the payer's property can be encumbered or seized if an arrearage accrues in an amount greater than the periodic support payments payable for two months under the payer's support order. 7. Change of Address, Employment Status, Health Insurance. Both parties shall notify each other in writing, within 21 days of any change in: a) their mailing and residential addresses and telephone numbers; b) the names, addresses, and telephone numbers of their sources of income; c) their health-maintenance or insurance companies, insurance coverage, persons insured, or contract numbers; d) their occupational or drivers' licenses; and e) their social security numbers unless exempt by law pursuant to MCL 552.603. 8. Foster-Care Assignment. When a child is placed in foster care, that child's support is assigned to the Department of Human Services while under the state's jurisdiction and to the funding county while placed in a county-funded program. 9. Prior Orders. This order supersedes all prior child-support orders and all continuing provisions are restated in this order. Past-due amounts owed under any prior support order are preserved. 10. Deviation. The support provisions ordered do do not follow the child-support formula. (If there is a deviation, state the amount and reasons for deviation in item 11.) 11. Other: (Attach separate sheets as needed.) Plaintiff (if consent/stipulation) Date Defendant (if consent/stipulation) Date Plaintiff's attorney Date Defendant's attorney Date Prepared by: Name (type or print) Date Judge Bar no. CERTIFICATE OF MAILING I certify that on this date I served a copy of this order on the parties or their attorneys by first-class mail addressed to their last-known addresses as defined in MCR 3.203. Date Signature COURT USE ONLY MCL 552.14, MCL 552.517, MCL 552.517b(3), MCR 3.211 American LegalNet, Inc. www.FormsWorkFlow.com FOC 10a / 52a (3/12) UNIFORM CHILD SUPPORT ORDER, NO FRIEND OF COURT SERVICES, PAGE 2