COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : INSTRUCTIONS: Plaintiff(s) Index No. Calendar No. JUDICIAL SUBPOENA -against: Order Information: Check the box that most accurately describes the type of order being entered. If it is a dissolution of marriage, enter the place of marriage and indicate if child support is ordered. : Temporary support orders and paternity orders that contain child support are categorized as “child support order, without dissolution.” “Child support order” includes medical support orders. If the : order does not contain a child support order, social security numbers of the parties are not required Defendant(s) and only Parts 1, 2 and 9 need to be completed. : ...................................................... Parts 1 and 2: Provide information about the parties to the order. If there is a child support order, be sure to check the box that shows whether the party owes support (payer) or will receive support (payee). If a party is ordered to both pay and receive support, check the box labeled “both.” If there THE PEOPLE OF THE STATE OF NEW YORK is no support order, check the box labeled “N/A” for not applicable. If a party is ordered to pay $0 support, that party should be considered a payer. TO Part 3: Provide information about the children named in the order and indicate which parent or other party the children live with. If the parenting plan provides for shared residential parenting, circle “B” for both. If a child is not living with either parent, circle “O” and list the child’s name and address. GREETINGS: Part 4: Complete this part if support is ordered to be paid to an agency or an individual other than WE a parent. COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Part 5: Indicate whether any of the parties are protected from each other by a protective or located at County of If the inrestraining order., on yes, list the names of the protected parties. This includes any protected children.recessed room day of , 20 , at o'clock in the noon, and at any or adjourned date, to testify and give evidence as a witness in this action on the part of the Part 6: Provide information about the employment or other source of income of the party who is ordered to pay child support. If both parties are ordered to pay support, skip Part 6 and complete Part 10 instead. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Part 7: Provide information about was issued order. Check penalty of $50 and all ordered and the party on whose behalf this subpoenathe support for a maximum the type(s) of supportdamages sustained as a enter your failure to comply. result ofthe amount and how often it is due. (Example: $100 per week.) All orders should have a “begin” date; many will not have an “end” date. If both parties are ordered to pay support, skip Part 7 and complete Part 11 instead. Witness, Honorable , one of the Justices of the Court in , show If the order enters aCounty, forday ofdue support, 20 the total amount of the judgment. If the judgment past judgment includes amounts for penalties, fees or interest, list those amounts on the appropriate lines. List any special conditions of the support order. (Example: support is due until the child graduates (Attorney must sign above and type name below) from college.) Copy the information requested about the guidelines to this form from the guidelines worksheet. Attorney(s) children. If insurance is not Part 8: Provide information about health insurance coverage for thefor provided, indicate whether it is available through the employer of either parent. Relationship of the party providing insurance is the party’s relationship to the children. (Example: mother, father, mother’s spouse, father’s spouse.) List the terms and conditions of the insurance coverage. Office (Example: 80/20 plan, $500 deductible, major medical only.) and P.O. Address Part 9: Provide information about the person completing this form. Telephone No.: Part 10: Employment information for multiple payers. Complete only if both parties are ordered to Facsimile No.: pay support. See Part 6 instructions. E-Mail Address: Part 11: Order information for multiple payers. Complete only if both parties are ordered to pay Mobile Tel. No.: support. See Part 7 instructions. American LegalNet, Inc. www.USCourtForms.com 2 (Revised 7/1/99) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. MONTANA STATE : CASE REGISTRY AND VITAL STATISTICSIndex No. REPORTING FORM : Calendar No. DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES (See instructions on first page) : JUDICIAL SUBPOENA Plaintiff(s) County / Tribe __________________________________ Judicial District No._______ Cause No. _______________ -against: Date Decree/ Order Signed ________________________________ ' Child Support Order, without Dissolution (Includes ' Dissolution of Marriage : Temporary Support Orders and Paternity Orders with County that Issued Marriage License ___________________ Child Support) City, County, State of Marriage ________________________ : ' Legal Separation with Child Support Order Date of Marriage ___________________________________ ' Dependent Neglect / Juvenile Delinquency '. .With. Child.Support .Order . . . . . .Defendant(s) . . . . . . .: ......... ... .... ...... .... .......... ' Invalid Marriage - Specify Legal Grounds for Action ' Without Child Support Order (Complete Parts 1, 2 & 9 only) __________________________________________ ' Modification of Child Support Order ____________________________________________ THE PEOPLE OF THE STATE OF NEW' Payee 1 Mother/Wife: ' Payer YORK Both ' N/A Maiden Name: _________________________________ Name:_____________________________________________ SSN:_______________ Telephone: (____)__________ TO Last ' First Middle/Suffix Mailing Address:__________________________________________________________________________________ Street City State Zip Residential Address (if different from above):____________________________________________________________ GREETINGS: Date of Birth: ___________________________ Place of Birth: _____________________________ Race: _________ State / Foreign Country WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Driver’s License # / State _____________________________ Occupation: ___________________________________ , the Honorable at the Court located at County of Number of this marriage (1st, 2nd, etc.):_____ Date, City & State of previous marriage(s):________________________ in room2 Father/Husband: day of , on the , 20 at noon, and at any recessed ' Payer ' Payee ' , Both ' o'clock in the N/A or adjourned date, to testify and give evidence as a witness in this action on the part of the Name:_____________________________________________ SSN:_______________ Telephone: (____)__________ Last First Middle/Suffix Mailing Address:__________________________________________________________________________________ Street City Zip Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to State the party on Residential Addresssubpoena was issued for a maximum penalty of $50 and all damages sustained as a whose behalf this (if different from above):____________________________________________________________ result of your failure to comply. Date of Birth: ___________________________ Place of Birth: _____________________________ Race: ________ State / Foreign Country Driver’s License # Witness, Honorable / State _____________________________ ,Occupation: Justices of the one of the __________________________________ Court in day 2nd, , Number ofCounty, this marriage (1st,of etc.):_____20Date, City & State of previous marriage(s):________________________ ' 3 Other Payee: If support is to be paid to another payee, check here and complete Part 4. Names of Children Included in the Support Order Last First Middle Residing With ** (Attorney must sign above and type name below) Date of Birth Sex SSN _________________________________________ _________________ M F ___________________ M F B O _________________________________________ _________________ M F Attorney(s) for ___________________ M F B O _________________________________________ _________________ M F ___________________ M F B O _________________________________________ _________________ M F ___________________ M F B O _________________________________________ _________________ M F ___________________ M F B O _________________________________________ _________________ M F ___________________ M F B O Office and P.O. Address **M=Mother F=Father If any of the above-named children are not residing with a parent, list the child’s name and address : B=Both O=Other Telephone No.: ________________________________________________________________________________________________________ Facsimile No.: E-Mail Address: ________________________________________________________________________________________________________ Mobile Tel. No.: 1 American LegalNet, Inc. www.USCourtForms.com (Revised 7/1/99) COURT COUNTY . . . . . . . . .4. . .OF. . . .Payee:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other . . . . . : Index No. Name of person/agency owed support if not parent: ______________________________________________________ Last Name or Agency Name First Middle : Calendar No. Mailing Address:_________________________________________________________Telephone: (____)__________ Street 5 City State Zip : JUDICIAL SUBPOENA Plaintiff(s) Residential Address (if different from above): ___________________________________________________________ -against: Protective Order: Is a party to this action protected from another party to the action by an order of protection? ' Yes ' No If yes, enter name(s) of protected party(ies): _____________________________________________________________ : 6 Employer/Income Source Information: Provide information about the payer’s employment or periodic source of income. : (Attach additional pages if needed.) Defendant(s) ' Check here if this order requires both parties to pay :support and skip Parts 6 & 7 and complete Parts 8, 9, 10 & 11. ...................................................... _______________________________________________________________________________________________ Name of Employer or Source of Income Telephone ________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK Street City State Zip TO 7 Support Order: Date Order Signed:_________________ Check type of support and enter appropriate information Support Type Total Due Frequency If applicable, arrears due at time of order: $ ____________ Begin Date End Date Judgment Penalty* Fees* Interest* (*list amounts if included in judgment) GREETINGS: ' Child Support: $__________ per __________ ________ ________ $_______ $______ $_______ $______ WE COMMAND YOU, that all business __________ being laid aside, you and $_______ $______before ' Medical Support: $__________ per and excuses ________ ________ each of you attend $_______ $______ , the Honorable at the Court ' Spousal Support: $__________ per __________ ________ ________ $_______ $______ $_______ $______ located at County of (Alimony) in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjournedIs payer exempt and give evidence as a witness MCA 40-5-315? the part of ' Yes ' Tribal Order date, to testify from income withholding under in this action on ' No the List any special terms/conditions of the support order(s): _________________________________________________ _______________________________________________________________________________________________ Was the mother represented by an attorney? ' Yes ' No Was the father represented by an attorney? ' Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Yes ' No the party on whose behalf this subpoena was issued for a maximum penaltyguidelines worksheet: sustained as a Information from child support of $50 and all damages result of your failure to comply. Mother: “Income after Deductions”: $_________ “Credit for Payment of Expenses”: $_________ Father: “Income after Deductions”: $_________ “Credit for Payment of Expenses”: $_________ Witness, Honorable , one of the Justices of the 8 Health Insurance: (Attach additional pages 20needed.) Court in County, day of , if Is health insurance provided for the children? ' Yes ' No (If no, answer last question in this section) Name and relationship of party providing insurance: ________________________________ Policy No. _____________ (Attorney must sign above and type name below) Name of insurance carrier or health benefit plan: _________________________________________________________ Address of insurance carrier or health benefit plan: _________________________________________________________ Names of children covered:__________________________________________________________________________ Attorney(s) for Terms/conditions of coverage: _______________________________________________________________________ If children are not covered, is coverage available through: Mother’s employer? ' Yes ' No Father’s employer? ' Yes ' No 9 Office and P.O. Address This form was completed by: Name / Title: __________________________________________________________ Telephone: ________________ Signature: __________________________________ Date: _____________________ Telephone No.: Complete next page if both parties are ordered to pay child support. Information contained Facsimile No.:private and confidential. in this form is E-Mail Address: It may only be shared with courts, agencies and individuals authorized by MCA 40-5-923. Mobile Tel. No.: 3 American LegalNet, Inc. www.USCourtForms.com (Revised 7/1/99) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Multiple Payers: Complete Parts 10 and 11 only if the order requires both parties to pay support. 10 : Calendar No. Mother’s Employer/Income Source Information: Provide information about the mother’s employment or periodic source : of income. (Attach additional pages if needed.) JUDICIAL SUBPOENA Plaintiff(s) _______________________________________________________________________________________________ : Name of Employer or-againstSource of Income Telephone _______________________________________________________________________________________________ : City State Zip Street Father’s Employer/Income Source Information: Provide information about the father’s employment or periodic source : of income. (Attach additional pages if needed.) Defendant(s) : _______________________________________________________________________________________________ ...................................................... Name of Employer or Source of Income Telephone _______________________________________________________________________________________________ Street City State Zip THE PEOPLE OF THE STATE OF NEW YORK 11 Support Order: Date Order Signed:_________________ TO Mother’s Support Obligation If applicable, arrears due at time of order: $ _______ Check type of support and enter appropriate information GREETINGS: Support Type Total Due Frequency Begin Date End Date Judgment Penalty* Fees* Interest* (*list amounts if included in judgment) WE COMMAND YOU, that all business __________ being laid aside, you and $_______ $______ before ' Child Support: $__________ per and excuses ________ ________ each of you attend $_______ , the Honorable at the Court ' Medical Support: $__________ per __________ ________ ________ $_______ $______ $_______ located at County of ' Spousal Support: day of $__________ per __________ ________ ________ $_______ $______ $_______ in room , on the , 20 , at o'clock in the noon, and at any recessed (Alimony) or adjourned date, to testify and give evidence as a witness in this action on the part of the Is the mother exempt from income withholding under MCA 40-5-315? $______ $______ $______ ' No ' Yes ' Tribal Order Father’s Support Obligation If applicable, arrears due at time of order: $ ________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on Check type of support and enter appropriate information penalty of $50 and all damages sustained as a whose behalf this subpoena was issued for a maximum result of your failure to comply. Total Due Support Type Frequency Begin Date End Date Judgment Penalty* Fees* Interest* (*list amounts if included in judgment) Witness, Honorable ' Child Support: Court in County, ' Medical Support: ' Spousal Support: , one of the Justices of the $__________ per __________ ________ ________ $_______ $______ $_______ $______ $__________ per __________ ________ ________ $_______ $______ $_______ $______ $__________ per __________ ________ ________ $_______ $______ $_______ $______ day of , 20 (Alimony) (Attorney must sign above and type name below) Is the father exempt from income withholding under MCA 40-5-315? ' No ' Yes ' Tribal Order List any special terms/conditions of the support order(s): _________________________________________________ Attorney(s) for _______________________________________________________________________________________________ __________________________________________________________________________________________________ ' No Was the father represented by an attorney? ' Yes ' No Office and P.O. Address Information from child support guidelines worksheet: “Income after Deductions”: $_________ “Credit for Payment of Expenses”: $_________ “Income after Deductions”: $_________ “Credit for Payment of Expenses”: $_________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Was the mother represented by an attorney? Mother: Father: ' Yes 4 American LegalNet, Inc. www.USCourtForms.com (Revised 7/1/99)