IN THE DISTRICT COURT OF STATE OF OKLAHOMA Petitioner/plaintiff and Respondent/defendant Mail to: ) ) ) ) ) ) COUNTY Case no: OCSS FGN: (Oklahoma Child Support Services case number) OCSS, Central Case Registry, P.O. Box 248843, Oklahoma City, OK 73124-8843 or fax to: (405) 522-8901 Summary of Support Order This form must be completed and presented to the judge before the judge signs your order. The Oklahoma Child Support Services Central Case Registry needs this information to send child support payments. This form will NOT be put on file in the Courthouse. [43 O.S. § 120] 1. The judge made the following order: Temporary or What kind of case was heard by the judge? Juvenile; Modification of earlier order; Other type of case, explain: 2. Active Protective Order? Amount Child support Cash medical Fixed medical support Spousal support Arrearage payment Other: Total: 4. The judge ordered father, (name), or mother of the child(ren), (name), to provide health insurance for the child(ren), OR cash medical support in lieu of insurance because health insurance is not available at a reasonable cost. The judge said cash medical support should be discontinued when the child(ren) is enrolled in health insurance at a reasonable cost not to exceed $ . 5. Please fill in the boxes below about each child that the judge ordered support to be paid for in this court order. If there are more than four children, please complete another form. Federal law requires you to provide the information below. [42 U.S.C. § 666(a)(13)] Form 03EN003E revised 4-29-2010 may continue on next page, page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Final on / / (date). Divorce; Paternity; Enforcement of earlier order; or Yes No Begin date End date 3. The judge made the following support orders: Payor Child's first name Middle name Last name Date of birth Male/ female Social Security number 6. An income assignment is immediately ordered: Yes No The employer of the person ordered to pay support is: Employer name Area code Phone Street or P.O. Box mailing address City State Zip 7. Additional information: Obligor (The person ordered to pay support, the noncustodial parent): Date of birth Male/Female Social Security number Daytime phone with area code Employer phone with area code Obligee (The person receiving support, the custodial person): Date of birth Male/Female Social Security number Daytime phone with area code Employer phone with area code 8. Mailing information: Enter the mailing address to receive mail, to serve orders, and for notices to come to court. [Address of record ­ 43 O.S. § 112A] Obligor (The person ordered to pay support, the noncustodial parent): Street or P.O. Box mailing address City State Zip Obligee (The person receiving support, the custodial person): Street or P.O. Box mailing address City State Should payments go to a different address for the Obligee? If yes, enter here: Street or P.O. Box mailing address City Prepared by Zip Yes No State Zip Date Print name Area code and phone number Form 03EN003E revised 4-29-2010 may continue on next page, page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com