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) American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com