PLAINTIFF VS Obligor Obligee HEARING DATE / SUPERIOR COURT OF NEW JERSEY Chancery Division-Family Part DEFENDANT Obligor Uniform Summary Support Order COUNTY: ________________________________________________ Obligee WELFARE / U.I.F.S.A. # DOCKET # ________________________________________________ / CS# ______________________________________________________ With appearance by: PL Atty for PL ___________________________ IV-D Atty _______________________________________ This matter having been opened to the court by: Plaintiff DEF Atty for DEF ________________________________ County Probation Division _________________________________________ Defendant for an ORDER for: Paternity Support 1. State with Continuing Exclusive Jurisdiction: Visitation CHILD’S NAME County Welfare Agency Custody BIRTH DATE Probation Division Enforcement Modification / Increase / Decrease CHILD’S NAME 2A. 2E. 2C. BIRTH DATE 2D. 2B. Family Division 2F. 3. PATERNITY of child(ren) (# above) ________________ is hereby established and an ORDER of paternity is hereby entered. 4. 5. A Certificate of Parentage has been filed for child(ren) #___________ above. IT IS HEREBY ORDERED THAT: The obligor shall pay support to the New Jersey Family Support Payment Center in the amount of: + Child Support + Spousal Support payable = Arrears Payment Total effective Frequency Date NOTE: Child support is subject to a biennial cost-of-living adjustment in accordance with R. 5:6B 6. Child Support Guidelines Order 6A. 7. Worksheet attached. Support order shall be administered and enforced by the Probation Division in the county of Venue, __________________________ County. 8. ARREARS calculated at establishment hearing are based upon amounts and effective date noted above and total $__________________. 9. 10. ARREARS indicated in the records of the Probation Division, are $____________________ as of _____/_____/_____. GROSS WEEKLY INCOMES of the parties, as defined by the Child Support Guidelines, upon which this ORDER is based: OBLIGEE $____________________________ OBLIGOR $_____________________________ INCOME WITHHOLDING is hereby ORDERED on current and future income sources, including: Name of income source: Address of income source: _________________________________________ ____________________________________________ 11. Deviation reason: __________________________________________________________________ _________________________________________ ____________________________________________ OBLIGOR SHALL, however, make payments AT ANY TIME that the full amount of support and arrears is not withheld. 12. 12A. 12B. Medical Support coverage as available at reasonable cost shall be provided for the child(ren) spouse, by Obligor Obligee Both The parties shall pay unreimbursable health care expenses of the child(ren) which exceed $250.00 per child per year as follows: __________________% Obligor _______________% Obligee Pursuant to R 5:6A the obligee shall be responsible for the first $250.00 per child per year. If coverage is available, Medical Insurance I.D. card(s) as proof of coverage for the child(ren)/spouse shall be provided immediately upon availability to the Probation Division by the: Obligee Obligor Insurance currently provided by a non-party:____________________________________________________________________________. Health insurance benefits are to be paid directly to the health care provider by the insurer. Promulgated 08/29/11 to be effective 09/01/2011, CN 10284 page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DOCKET#_______________ 13. 13A. 14. 15. 16. 18. 19. 20. 21. 22. 23. HEARING DATE ____/____/____ PAGE 2 OF 2 GENETIC TESTING to assist the court in determining paternity of the child(ren) (#______) is hereby ORDERED. The county welfare agency or the foreign jurisdiction in the county of residence of the child shall bear the cost of said testing, without prejudice to final allocation of said costs. If defendant is later adjudicated the father of said child(ren), defendant shall reimburse the welfare agency for the costs of said tests, and pay child support retroactive to ____/____/____. Issues of reimbursement reserved. 13B. Issue of retroactive order reserved. This matter is hereby RELISTED for a hearing on _____/_____/_____ before ____________________________________. A copy of this ORDER shall serve as the summons for the hearings. No further notice for appearance shall be given. Failure to appear may result in a default order, bench warrant, or dismissal. Reason for relist: AN EMPLOYMENT SEARCH MUST BE CONDUCTED BY THE OBLIGOR. Written records of at least #_____ employment contacts per week must be presented to the Probation Division. If employed, proof of income and the full name and address of employer must be provided immediately to the Probation Division. SERVICE upon which this order is based: Personal Service Date: ____/____/____ 17. CS#_____________________ Certified Mail: Signed by: ______________________ Refused Returned Unclaimed Regular Mail (not returned) Other: A BENCH WARRANT for the arrest of the obligor is hereby ORDERED. The obligor was properly served with notice for court appearance on ____/____/____, and failed to appear. (Service noted above). An amount of $ ___________ shall be required for release. EFFECTIVE ___/___/___ FUTURE MISSED PAYMENT(S) numbering ________ or more may result in the issuance of a warrant, without further notice. A LUMP SUM PAYMENT OF $_________ must be made by the obligor by _____/_____/_____, or a bench warrant may be issued without further notice. This complaint / motion is hereby DISMISSED: (reason) __________________________________________________________________ Order of Support is hereby TERMINATED effective _____/_____/_____, as ___________________________________________________. Arrears accrued prior to effective date, if any, shall be paid at the rate and frequency noted on page number one of this ORDER. THIS ORDER IS ENTERED BY DEFAULT. The obligor obligee was properly served to appear for a hearing on _____/_____/_____ and failed to appear. 22A. Affidavit of Non-Military Service is filed. It is further ORDERED: ___________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ EXCEPT AS PROVIDED HEREIN, ALL PRIOR ORDERS OF THE COURT REMAIN IN FULL FORCE AND EFFECT. I hereby declare that I understand all provisions of this ORDER recommended by a Hearing Officer and I waive my right to an immediate appeal to a Superior Court Judge: PLAINTIFF _____________________________________________ DEFENDANT ___________________________________________________ ATTORNEY FOR PLAINTIFF_______________________________ ATTORNEY FOR DEFENDANT _____________________________________ 24. INTAKE CONFERENCE BY AUTHORIZED COURT STAFF: 25. The parties request the termination of all Title IV-D services and consent to direct payment of support. They are advised that all monitoring, collection, enforcement and location services available under Title IV-D of the Social Security Act are no longer in effect. I understand I may reapply for Title IV-D services. _____________________________________ _____________________________________ obligee obligor 26. Copies provided at hearing to obligee obligor 26A. Copies to be mailed to obligee obligor TAKE NOTICE THAT THE NEW JERSEY UNIFORM SUPPORT NOTICES WHICH ARE PROVIDED IN APPENDIX XVI OF THE RULES OF COURT, AND WHICH FOLLOW, ARE INCORPORATED INTO THIS ORDER BY REFERENCE AND ARE BINDING ON ALL PARTIES. So Recommended to the Court by the Hearing Officer: Date / / H.O. Signature Judge Signature 0 1 So Ordered by the Court: Date / / Promulgated 08/29/11 to be effective 09/01/2011, CN 10284 J.S.C. page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com UNIFORM SUMMARY SUPPORT ORDER (R. 5:7-4) NEW JERSEY UNIFORM SUPPORT NOTICES PURSUANT TO R. 5:7-4(f), TAKE NOTICE THAT THE FOLLOWING PROVISIONS ARE TO BE CONSIDERED PART OF THIS ORDER AND ARE BINDING ON ALL PARTIES: 1. You must continue to make all payments until the court order is changed by another court order. 2. You must file a WRITTEN request to the Family Division in the county in which the order was entered in order for the court to consider a change in the support order. Contact the Family or Probation Division to find out how to do this. It is important that you request a change as soon as possible after your income or the child(ren)’s status changes. In most cases, if you delay making your request, and you are the obligor, you will have to pay the original amount of support until the date of your written request. 3. Payments must be made directly to the New Jersey Family Support Payment Center, P.O. Box 4880, Trenton, NJ 08650, unless the court directs otherwise. Payments may be made by money order, check, direct debit from your checking account, or credit card. Gifts, other purchases, or in-kind payments made directly to the obligee or child(ren) will not fulfill the support obligation. Credit for payments made directly to the obligee or child(ren) may not be given without a court order. 4. No payment or installment of an order for child support, or those portions of an order that are allocated for child support, shall be retroactively modified by the court except for the period during which the party seeking relief has pending an application for modification as provided in N.J.S.A. 2A:17-56.23a. (R. 5:7-4(e)). 5. The amount of child support and/or the addition of a health care coverage provision in Title IV-D cases shall be subject to review at least once every three years, on written request by either party to the Division of Family Development, P.O. Box 716, Trenton, NJ 08625-0716, as appropriate, or upon application to the court. (N.J.S.A. 2A: 1756.9a; R. 5:7-4(e)). 6. In accordance with N.J.S.A. 2A:34-23b, the custodial parent may require the noncustodial parent's health care coverage provider to make payments directly to the health care provider by submitting a copy of the relevant sections of the order to the insurer. (R. 5:7-4(e)). 7. Social Security numbers are collected and used in accordance with section 205 of the Social Security Act (42 U.S.C. 405). Disclosure of an individual's Social Security number for Title IV-D purposes is mandatory. Social Security numbers are used to obtain income, employment, and benefit information on individuals through computer matching programs with federal and state agencies, and such information is used to establish and enforce child support under Title IV-D of the Social Security Act (42 U.S.C. 651 et seq.). Any person who willfully and with the intent to deceive, uses a Social Security number obtained on the basis of false information provided to Social Security Administration or provides a false or inaccurate Social Security number is subject to a fine or imprisonment. (42 U.S.C. 408(7); R. 5:7-4(e)). Promulgated 08/29/11 to be effective 09/01/2011, CN 10284 page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 8. The United States Secretary of State is required to refuse to issue or renew a passport to any person certified as owing a child support arrearage exceeding the statutory amount. In addition, the U.S. Secretary of State may take action to revoke, restrict or limit a passport previously issued to an individual owing such a child support arrearage. (42 U.S.C. 652(k)). 9. Failure to appear for a hearing to establish or to enforce an order, or failure to comply with the support provisions of this order may result in incarceration. The obligee and obligor shall notify the appropriate Probation Division of any changes in address, employment status, health care coverage, or a change in the address or status of the child(ren). Changes must be reported in writing to the Probation Division within 10 days of the change. Not providing this information is a violation of this Order. The last address you give to Probation will be used to send you notices. If you fail to appear, a default order may be entered against you or a warrant may be issued for your arrest (R. 5:7-4(e)). 10. Any payment or installment for child support shall be fully enforceable and entitled to full faith and credit and shall be a judgment by operation of law on or after the date it is due (N.J.S.A. 2A:17-56.23a). Any non-payment of child support you owe has the effect of a lien against your property. This child support lien may affect your ability to obtain credit or to sell your property. Failure to remit timely payment automatically results in the entry of a judgment against the obligor and post-judgment interest may be charged. Judgments [also] accrue interest at the rate prescribed by Rule 4:42- 11(a). (R. 5:7-4(e), 5:7-5(g)). Before the satisfaction of the child support judgment, any party to whom the child support is owed has the right to request assessment of post-judgment interest on child support judgments. 11. All child support obligations are payable by income withholding unless otherwise ordered. If immediate income withholding is not required when an order is entered or modified, the child support provisions of the order may be subject to income withholding when the amount due becomes equal to, or in excess of the amount of support due for 14 days. The withholding is effective against the obligor’s current and future income from all sources authorized by law. (R. 5:7-4(e), R. 5:7-5). 12. The occupational, recreational, and professional licenses, including a license to practice law, held or applied for by the obligor may be denied, suspended or revoked if: 1) a child support arrearage accumulates that is equal to or exceeds the amount set by statute, or 2) the obligor fails to provide health care coverage for the child as ordered by the court, or 3) a warrant for the obligor's arrest has been issued by the court for obligor's failure to pay child support as ordered, or for obligor's failure to appear at a hearing to establish paternity or child support, or for obligor's failure to appear at a child support hearing to enforce a child support order and said warrant remains outstanding. (R. 5:7-4(e)). 13. The driver's license held or applied for by the obligor may be denied, suspended, or revoked if 1) a child support arrearage accumulates that is equal to or exceeds the amount set by statute, or 2) the obligor fails to provide health care coverage for the child as ordered by the court. The driver's license held or applied for by the obligor shall be denied, suspended, or revoked if the court issues a warrant for the obligor's arrest for failure to pay child support as ordered, or for failure to appear at a hearing to establish paternity or child support, or for failure to appear at a child support hearing to enforce a child support order and said warrant remains outstanding. (R. 5:7-4(e)). Promulgated 08/29/11 to be effective 09/01/2011, CN 10284 page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 14. The name of any delinquent obligor and the amount of overdue child support owed will be reported to consumer credit reporting agencies as a debt owed by the obligor, subject to all procedural due process required under State law. (N.J.S.A. 2A: 17-56.21). 15. Child support arrears may be reported to the Internal Revenue Service and the State Division of Taxation. Tax refunds/homestead rebates due the obligor may be taken to pay arrears (N.J.S.A. 2A:17-56.16). 16. Child support arrears shall be paid from the net proceeds of any lawsuit, settlement, civil judgment, civil arbitration award, inheritance or workers’ compensation award to a prevailing party or beneficiary before any monies are disbursed. (N.J.S.A. 2A:1756.23b). 17. Periodic or lump sum payments from State or local agencies, including lotteries, unemployment compensation, workers’ compensation or other benefits, may be seized or intercepted to satisfy child support arrearages. (N.J.S.A. 2A:17-56.53). 18. If you owe past due child support, your public or private retirement benefits, and assets held in financial institutions may be attached to satisfy child support arrearages. (N.J.S.A. 2A:17-56.53). 19. A person under a child support obligation, who willfully fails to provide support, may be subject to criminal penalties under State and Federal law. Such criminal penalties may include imprisonment and/or fines. (N.J.S.A. 2C:24-5; N.J.S.A. 2C:62-1; 18 U.S.C.A. 22). 20. If this order contains any provision concerning custody and/or parenting time, both parties are advised: Failure to comply with the custody provisions of this court order may subject you to criminal penalties under N.J.S.A. 2C:13-4, Interference with Custody. Such criminal penalties include, but are not limited to, imprisonment, probation, and/or fines. Si usted deja de cumplir con las clausulas de custodia de esta ordern del tribunal, puede estar sujeto (sujeta) a castigos criminales conforme a N.J.S.A. 2C:13-4, Interference with Custody, (Obstruccion de la Custodia). Dichos castigos criminales incluyen pero no se limitan a encarcelamiento, libertad, multas o una combinacion de los tres. Promulgated 08/29/11 to be effective 09/01/2011, CN 10284 page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com