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Consent Agreement And Order To Modify Child Support Order Form. This is a North Carolina form and can be use in Civil Statewide.
Tags: Consent Agreement And Order To Modify Child Support Order, CV-615, North Carolina Statewide, Civil
STATE OF NORTH CAROLINA
IV-D Case No.
Court File No.
Film No.
County
In The General Court Of Justice
District Court Division
Name Of Plaintiff
CONSENT AGREEMENT AND ORDER
TO MODIFY CHILD SUPPORT ORDER
VERSUS
Name Of Defendant
G.S. 50-13.4
Name And Address Of Obligor
Date Of Current Support Order
Name And Address Of Custodial Parent/Caretaker
Current Amount Of Child Support
$
Weekly
Bi-weekly
Monthly
Other (specify)
Non IV-D
IV-D
Wage Withholding
In Effect
We, the undersigned, have agreed and consented to modify the current child support order in this case as follows:
Increase Or Decrease In Current Child Support. The amount of child support payable by the obligor will be
increased
decreased to $
per month beginning on the first day of
(month/year). The information shown on the attached child support worksheet is correct. The amount of child support
agreed to above
was
was not determined in accordance with the presumptive child support guidelines
based on the attached child support worksheets. (Complete and attach a child support worksheet.)
Payment Of Child Support Arrearages. The parties acknowledge and agree that the obligor owes $
in past due child support as of
(date) under the terms of the current support order. The
obligor will continue to make current child support payments of $
per month beginning on the first
day of
(month/year) under the current support order, plus an additional payment of
$
per month beginning on the first day of
(month/year) toward the accrued
arrearage and continuing until arrearage is paid in full. The parties further understand and agree that the obligor's
payment of arrearages under this Consent Order does not prevent the custodial parent/caretaker or the IV-D agency
from taking other action, including request for income withholding and/or set-off of the obligor's federal or state income
tax refunds, to collect the past due child support owed by the obligor.
Health Insurance Coverage. The obligor agrees to provide health insurance coverage for the minor child(ren) under
an employment related or group health insurance policy as shown below, and to provide written notice of any change
in such health insurance coverage to the
IV-D agency
custodial parent/caretaker. If the obligor fails to
obtain or maintain such health insurance coverage when it is available, the obligor will be liable for any medical
expenses incurred from the date of this Consent Order that would have been covered by insurance if it had been in
force.
Employer/Group Name
Name And Address Of Insurance Carrier
Policy No.
Medical Support. The obligor agrees to reimburse the Division of Medical Assistance or the custodial parent/
caretaker for medical and/or dental expenses of the minor child(ren) as follows:
Temporary Suspension Of Support. The obligor may temporarily suspend making child support payments under the
current support order
beginning
(date) and continuing until
(date)
or
until further order of the court. (State reason for suspending child support payments.)
AOC-CV-615, Rev. 3/09
© 2009 Administrative Office of the Courts
(Over)
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Temporary Change Of Physical Custody and Child Support Payments. The obligor will have physical custody of
the following minor child(ren):
Name(s)
Beginning Date
The obligor's child support obligation under the current support order is
$
per month beginning on the first day of
support payments under the current child support order are to resume on
month).
Ending Date
suspended
decreased to
(month/year). Regular child
(first day of
Credit For Direct Payments. The obligor will be given credit for $
which was paid directly to the
custodial parent/caretaker or expended by the obligor on behalf of the minor children.
Date
Name Of IV-D Agent Or Attorney (Type Or Print)
Signature Of IV-D Agent Or Attorney
NOTE: If parties appear in open court, notarization is not necessary.
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Date
Signature Of Obligor
Signature Of Custodial Parent/Caretaker
Name Of Obligor (Type Or Print)
Name Of Custodial Parent/Caretaker (Type Or Print)
Date
Date
Signature
Title Of Person Authorized To Administer Oaths
Deputy CSC
Assistant CSC
Signature
Title Of Person Authorized To Administer Oaths
Deputy CSC
Clerk Of Superior Court
Date My Commission Expires
Assistant CSC
Clerk Of Superior Court
Date My Commission Expires
Notary
Notary
County Where Notarized
County Where Notarized
SEAL
SEAL
ORDER
The above Agreement, the terms of which are incorporated by reference herein, is hereby approved by the Court, and shall have the
same force and effect as an order for child support entered by this Court, and shall be enforceable and subject to modification in the
same manner as is provided by law for orders of this Court entered in child support cases.
If income withholding is in effect, the Clerk shall issue an Order/Notice To Withhold Income For Child Support (OMB-0970- 0154),
reflecting the changes in this Order.
The Court finds that the amount of child support under this Agreement is:
the amount due under the presumptive child support guidelines based upon the incomes of the parents shown on the attached
child support worksheets which are incorporated herein by reference
OR
reasonably based upon the needs of the child(ren) and the ability of the parent(s) to support the child(ren) and that deviation from
the amount of child support calculated under the presumptive child support guidelines is appropriate because: (State reasons for
deviation.)
Date
Name Of Judge (Type Or Print)
AOC-CV-615, Side Two, Rev. 3/09
© 2009 Administrative Office of the Courts
Signature Of Judge
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