THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: UNIFORM SUPPORT ORDER Name, Residence and Mailing Address of Person Ordered to Pay Support (Obligor) Telephone D.O.B. Name, Residence and Mailing Address of Person Receiving Support (Obligee) Telephone D.O.B. E-mail Address E-mail Address Name of Employer: Name of Employer: Address of Employer: Address of Employer: Child(ren) to whom this order applies: Full Name Date of Birth NOTE: SECTIONS PRECEDED BY Full Name Date of Birth ARE ONLY PART OF THIS ORDER IF MARKED. 1. This order is entered: 2. This order is a: after hearing temporary order upon approval of agreement final order upon default enforcement 3. This order modifies a final support obligation in accordance with: a three-year review (RSA 458-C:7) OR substantial change in circumstances, as follows: NHJB-2066-FS (07/01/2008) Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: UNIFORM SUPPORT ORDER 4. Obligor is ORDERED to PAY THE FOLLOWING AMOUNTS: CHILD SUPPORT: $ per Arrearage of $ (week, month, etc.) as of payable $ , per (week, month, etc.) Medical arrearage of $ payable $ as of per , (week, month, etc.) SPOUSAL SUPPORT (ALIMONY): $ Arrearage of $ per as of per payable $ (week, month, etc.) , (week, month, etc.) Alimony shall terminate . All ordered amounts 5. Payments on all ordered amounts shall begin on shall be payable to 6. Obligee Division of Child Support Services Other This order complies with the child support guidelines. RSA 458-C. This order, entered upon obligor’s default, is based on a reasonable estimate of obligor’s income. Compliance with the guidelines cannot be determined. The following special circumstances warrant an adjustment from the guidelines: (see Instructions for these special circumstances and enter applicable circumstances below) 7. Support ordered is payable by immediate income assignment. 8. The Court finds that there is good cause to suspend the immediate income assignment because: Obligor and obligee have agreed in writing. Payments have been timely and it would be in the best interest of the minor child(ren) because: 9A. Obligor is unemployed and MUST REPORT EFFORTS TO SEEK EMPLOYMENT. (See Standing Order 9). 9B. Upon employment the Obligor shall bring the matter forward for recalculation of support. Failure to do so may result in a recalculated support order effective the date of employment. MEDICAL SUPPORT FINDINGS (Paragraphs 10 through 15) 10. OBLIGOR’S reasonable cost is calculated to be $ etc.) (See Standing Order 10) 11. Health insurance coverage per 12. is not (week, month, etc.) per (week, month, is available to the OBLIGOR at $ which amount is not is deemed to be reasonable. Health insurance coverage available to the OBLIGOR is not accessible to the child(ren). NHJB-2066-FS (07/01/2008) Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: UNIFORM SUPPORT ORDER 13. OBLIGEE’S reasonable cost is calculated to be $ month, etc.) (See Standing Order 10) 14. Health insurance coverage per 15. is not (week, month, etc.) per (week, is available to the OBLIGEE at $ which amount is not is deemed to be reasonable. Health insurance coverage available to the OBLIGEE is not accessible to the child(ren). MEDICAL SUPPORT OBLIGATION (Paragraph 16A and/or 16B must be completed): 16A. Obligor Obligee is ordered to provide health insurance coverage for the child(ren) effective 16B. (See Standing Order 16A) Obligor Obligee is/are not ordered to provide health insurance coverage at this time but is/are ordered to immediately obtain health insurance coverage when it becomes accessible and available at reasonable cost. 17. Uninsured medical expenses shall be paid in the following percentage amounts: Obligor % Obligee % Other %. 18. Public assistance (TANF) or medical assistance (Medicaid) is or was provided for the children. Copies of pleadings related to medical coverage and child support were mailed to the Division of Child Support Services, Child Support Legal, 129 Pleasant Street, Concord, NH 03301. 19. Obligor Obligee is adjudicated the father of the minor child(ren) named above. The clerk of the city(ies) of shall enter the name of the father on the birth certificate(s) of the child(ren). The father’s date of birth is and his state of birth is . 20. The State of has provided $ in public assistance for the benefit of the minor child(ren) between and for weeks. Obligor is indebted for the assistance in the total amount of $ 21. Variation to standing order (specify paragraph #), additional agreement or order of the Court: Obligor Obligee Obligor’s Attorney/Witness Obligee’s Attorney/Witness Date Date NHJB-2066-FS (07/01/2008) Staff Attorney Division of Child Support Services Date Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: UNIFORM SUPPORT ORDER All paragraphs of this order (except those that have a check box and have not been selected) and all paragraphs of the Standing Order, (except variations in paragraph 21) are part of this order and apply to all parties. Recommended: Signature of Marital Master/Referee Date Name of Marital Master/Referee Date Name of Judge So Ordered: Signature of Judge THE STATE OF NEW HAMPSHIRE UNIFORM SUPPORT ORDER — STANDING ORDER NOTICE: This Standing Order (SO) is a part of all Uniform Support Orders (USO) and shall be given full effect as order of the Court. Variations to paragraphs of the SO in a specific case must be entered in paragraph 16 of the USO and approved by the Court. (Paragraph numbers in the SO correspond to related paragraph numbers in the USO. Variations entered in paragraph 21 should reference the related paragraph number.) SUPPORT PAYMENT TERMS SO-3A. All prior orders not inconsistent with this order remain in full force and effect. SO-3B. This order shall be subject to review and modification three years from its effective date upon the request of a party. Any party may petition the Court at any time for a modification of this support order if there is a substantial change in circumstances. Except as otherwise provided, the effective date of any modification shall be no earlier than the date of notice to the other party. SO-4A. An obligation for child support terminates when a child terminates his/her high school education or reaches the age of 18 years, whichever is later, or gets married, or becomes a member of the armed services. SO-4B. The amount of child support may be recalculated according to the guidelines whenever there is a change in the number of children for whom support is ordered, upon petition of any party. SO-4C. In cases payable through the New Hampshire Division of Child Support Services (DCSS), if there are arrearages when support for a child is terminated, payments on the arrearages shall increase by the amount of any reduction of child support until the arrearages are paid in full. SO-4D. Pursuant to RSA 161-C:22, III when an assignment of support rights has terminated and obligor and the recipient of public assistance reunite, obligor may request a suspension of the collection of support arrearage owed to the state under RSA 161-C:4. So long as the family remains reunited and provided that the adjusted gross income of the family as defined by RSA 458-C is equal to or less than 185% of the Federal poverty guidelines as set by the United States Department of Health and Human Services, DCSS shall not take any action to collect the support arrearage owed to the State. SO-4E. If the collection of a support arrearage pursuant to RSA 161-C:4 is suspended, the obligor shall provide DCSS with a financial affidavit every six months evidencing the income of the reunited family and shall notify his or her child support worker in writing within ten days of any change in income or if the family is no longer reunited. Failure to report changes in income or in the status of the family as reunited or to provide a financial affidavit shall cause the suspension of collection to terminate. SO-4F. Each party shall inform the Court in writing of any change in address, within 15 days of the change, so long as this order is in effect. Service of notice of any proceeding related to this order shall be sufficient if made on a party at the last address on file with the Court. A party who fails to keep the Court informed of such a change in address, and who then fails to attend a hearing because of the lack of notice, may be subject to arrest. SO-5A. If no date appears in paragraph 5 of the USO, the first support payment shall be due on the date this order is signed by the Judge. NHJB-2066-FS (07/01/2008) Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: UNIFORM SUPPORT ORDER SO-5B. If support is payable through DCSS, DCSS is authorized and directed to collect all sums, including any arrearages, from the obligor and forward the sums collected to the obligee or person, department, or agency providing support to the children named in the USO. Any payment shall be applied first as payment towards the current child and medical support obligation due that month and second towards any arrearages. SO-5C. If support is ordered payable directly to the obligee, it can only be made payable through DCSS at a later time if (1) the children named in the USO receive assistance pursuant to RSA 161 or RSA 167; (2) a party applies for support enforcement services and certifies to DCSS that (a) an arrearage has accumulated to an amount equal to the support obligation for one month, or (b) a court has issued a protective order pursuant to RSA 173-B or RSA 461-A:10 which remains in full force and effect at the time of application; or (3) a court orders payment through DCSS upon motion of any party that it is in the best interest of the child, obligee, or obligor to do so. RSA 161-B:4. SO-5D. Collection by DCSS on any arrearage may include intercepting the obligor’s federal tax refund, placing liens on the obligor’s personal and real property including qualifying financial accounts. Federal tax refund intercept and lien remedies shall be used to collect arrearages even if an obligor is complying with the child support orders. Pursuant to 45 CFR 303.72 (h) any federal tax refund intercept shall be applied first as payment towards the past due support assigned to the State. SO-5E. In all cases where child support is payable through DCSS, obligor and obligee shall inform DCSS in writing of any change of address or change of name and address of employer, within 15 days of the change. SO-5F. In all cases where child support is payable through DCSS, obligor and obligee shall furnish their social security numbers to the New Hampshire Department of Health and Human Services (Department). INCOME ASSIGNMENT SO-7A. Until such time as an income assignment goes into effect, payments shall be made as follows: (1) if the case is not payable through DCSS, directly to obligee, or (2) if support is payable through the DCSS by use of payment coupons available at the local DCSS office. An income assignment will not go into effect for selfemployed obligors as long as they do not receive income as defined in RSA 458-B:1, paragraph IX. Future income will be subject to assignment if the case is payable through DCSS. SO-7B. If a parent is ordered to provide health coverage for Medicaid-eligible child(ren), he or she must use payments received for health care services to reimburse the appropriate party, otherwise his or her income may be subject to income assignment by DCSS. RSA 161-H:2(V). SO-7C. Increased income assignment for the purposes of payment on arrearages shall continue until such time as the arrearages are paid in full. SO-8. Whenever an income assignment is suspended, it may be instituted if a Court finds obligor in violation or contempt of this order OR after notice and the opportunity to be heard (RSA 458:B-5 & 7), when the Department begins paying public assistance for the benefit of a child OR when an arrearage amounting to the support due for a one-month period has accrued. REPORT CHANGES OF EMPLOYMENT SO-9A. If support is payable through DCSS, obligor shall report in writing weekly, or as otherwise ordered by Court, to DCSS, and shall provide details of efforts made to find a job. Efforts to obtain employment shall include registering with New Hampshire Employment Security within two weeks of the date of this order. The obligor shall immediately report employment to DCSS in writing. SO-9B. Immediately upon employment the obligor shall report to the obligee, in writing, details of employment, including name and address of employer, the starting date, number of weekly hours and the rate of pay. MEDICAL SUPPORT PROVISION SO-10-16B. In all cases where support is payable through DCSS, or where the Department is providing medical assistance for the child(ren) pursuant to RSA 167, the court shall include the medical support obligation in any child support order issued. RSA 461-A:14, IX(d). Health insurance shall be available at a reasonable cost if the cost of such insurance does not exceed 4 percent of the responsible parent’s individual gross income under RSA 458-C:2, VI-a. RSA 461-A:14, IX(b). SO-12. Accessible health insurance means the primary care services are located within 50 miles or one hour from the child(ren)’s primary residence. RSA 461-A:14, IX(b). SO-16A. A party providing or ordered to provide health insurance for the child(ren) shall give the other party sufficient information and documentation to make sure insurance coverage is effective. If support is payable through DCSS, or if there has been an assignment of medical support rights to DCSS, the information and documentation shall be provided to DCSS. In addition, obligor shall inform DCSS in writing when health insurance is available, obtained or discontinued. NHJB-2066-FS (07/01/2008) Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com