1 CODE:3980 Name: 2 Address: 3 Telephone: Name: 4 Address: 5 Telephone: 6 Acting in Proper Person IN THE FAMILY DIVISION 7 OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 8 IN AND FOR THE COUNTY OF WASHOE 9 10 11 Petitioner, Case No. 12 vs. Dept. No. 13 14 Respondent. ________________________________/ 15 16 JUDGMENT AND ORDER UPON STIPULATION FOR UNREIMBURSED HEALTH CARE EXPENSES 17 18 The above-named parties hereby stipulate to the entry of an Order as follows: 19 1. Respondent is the parent of: 20 NAME OF CHILD(REN) DATE OF BIRTH 21 22 23 24 25 26 2. A judgment is to be entered against the Respondent for arrears in Unreimbursed health 27 care expenses for the minor child(ren) in the amount of $ , said 28 amount representing those sums due and owing from through Ct. App. 7/99 1 American LegalNet, Inc. www.USCourtForms.com>>>> 2 1 and the Respondent shall pay $ per month to 2 retire the judgment beginning . Said payment shall be made 3 in addition to the child support payment. 4 3. No interest shall accrue on the arrearage so long as Respondent remains current on 5 monthly payments. Should Respondent becomety (30) days delinquen thir t, or, should a pattern 6 of over ten (10) days delinquency in payments develop without stipulation and acceptance by the 7 Petitioner, Pursuant to NRS 125B.140, as amended, interest upon the arrearage shall accrue at a 8 rate established pursuant to NRS 99.040, from the time each amount became due. 9 4. All property is subject to actions for collection including, but not limited to, 10 withholding of wages, garnishment, liens, and the attachment of federal income tax refunds. 11 5. All payments must be made payable as follows: 12 In accordance with Nevada Revised Statue 425.410 and federal law, all Nevada child 13 support payments currently paid to a Nevada child support agency must be sent to: 14 STATE COLLECTION AND DISBURSEMENT UNIT (ScaDU) 15 PO BOX 98950 16 LAS VEGAS, NV 89193-8950 17 PLEASE NOTE: PAYMENTS MUST BE BY MONEY ORDER OR CASHIER 18 CHECK AND PAYA BLE TO ScaDU 19 The following information must be included with each payment: 20 1. Name (first, middle, last) of person responsible for child support 21 2. Social Security Number of person responsible for child support 22 3. Name of custodian (first and las name of person receiving child support) t 23 4. Child support case number 24 If you have any questions regarding where to send your child support payments, 25 please call your local District Attorney Family Support Division at (775) 789-7100. 26 NOTICE: NO CREDIT WILL BE GIVEN FO R PAYMENTS PAID DIRECTLY TO THE 27 PETITIONER. 28 // Ct. App. 7/99 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 1 The Respondent is responsible for notifying the District Attorneys Office, Family Support 2 Division, in writing, of any change of address, change of employment, change of custody, or 3 entry of any other order relative to child support, within five (5) days of such change. 4 DATE:____________________________ DATE:____________________________ 5 __________________________________ __________________________________ 6 (Petitioners Signature) (Respondents Signature) 7 8 SUBSCRIBED AND SWORN to before me SUBSCRIBED AND SWORN to before me 9 this ______ day of ____________, _______. this ______ day of ____________, _______. 10 11 _____________________________________ __________________________________ __ NOTARY PUBLIC NOTARY PUBLIC 12 13 14 ORDER AND JUDGMENT 15 Based upon the above Stipulation of the parties in this action; and, 16 The Court, being fully advised of the facts and circumstances in this matter, 17 IT IS HEREBY ORDERED that the Stipulation is affirmed and Judgment is hereby 18 entered against Respondent in the amount of $___________________________ ____. 19 IT IS FURTHER ORDERED that the Respondent shall satisfy the Judgment in the 20 manner agreed upon, and stated above. 21 DATE:____________________________ 22 23 24 ______________________________ DISTRICT JUDGE 25 26 27 28 Ct. App. 7/99 3 American LegalNet, Inc. www.USCourtForms.com