FORM 5A IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN ) ) ) ) ) ) ) ) ) ) ) ______________________________, Petitioner, and Case No. ______________________ _____________________________, Respondent. CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDINGS and/or EXISTING CHILD SUPPORT ORDERS/JUDGMENTS (UTCR 8.090) I hereby certify that: 1. PENDING CHILD SUPPORT PROCEEDINGS (include any child support matter being heard by either a court or agency as part of a dissolution, separation, annulment, paternity, juvenile court, support or modification case): There is no pending child support proceeding in this or any other state involving the parties' child[ren]. There is a pending child support proceeding in Oregon in another state which involves the parties' child[ren] as follows: Name/County of Court or Agency where pending: Agency Case Number: 2. EXISTING CHILD SUPPORT ORDERS OR JUDGMENTS (include any order/judgment whether made by an agency or There are no other child support orders/judgments in this or any other state involving the parties' child[ren]. There is/are other child support orders/judgments involving the parties' child[ren], as follows: court in this or any other state, and whether or not currently effective): ORDER/JUDGMENT #1 (Attach a copy of the order) Name/County of Court or Agency where issued: Case Number: Date of Order: ORDER/JUDGMENT #2 (Attach a copy of the order): Name/County of Court or Agency where issued: Case Number: Date of Order: Attach additional sheets if necessary, labeled "Attachment 1 to Certificate Re: Child Support Proceedings and Orders". Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to _____________________________ for assistance in preparing this form. DATED this _____ day of _______________________, 20______. ________________________________________________________________________________________ Petitioner Respondent, Signature Print Name ________________________________________________________________________________________ Contact Address Telephone or Contact Telephone PageCounty Disso-1B: Form 5A Certificate of Pending Child Support Proceedings.wpd (8/09) Linn 1 of 1, CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDINGS and/or EXISTING CHILD SUPPORT ORDERS/JUDGMENTS (UTCR 8.090) American LegalNet, Inc. www.FormsWorkFlow.com