IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN In the Matter of: ) ) ________________________________, ) Petitioner, ) ) and ) ) ________________________________, ) Respondent. ) ) and ) ) ________________________________, ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) ) Case No. ______________________ PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 and CHILD SUPPORT DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 Petitioner is the mother father and Respondent is the mother father of (names of children): , born on the following date/s: 1. Paternity has been established: by filing with the State Registrar of Vital Statistics a voluntary acknowledgment of paternity, concerning the following child/ren (e.g., birth certificate): (list name/s of child/ren involved) by administrative order docketed with the following court: , as case number , located in county, concerning the following child/ren: 2. (list name/s of child/ren involved) by judicial order entered in the following court: : , as case number , located in county, concerning the following child/ren: (list name/s of child/ren involved) by another method: concerning the following child/ren: (list name/s of child/ren involved) /// PETITION FOR CUSTODY AND PARENTING TIME - PAGE 1 of 7 Unmarried Parents-3A: Form 1 Petition for Custody 2010.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com 3. The minor child/ren reside/s in County, State of County, State of County, State of The minor child/ren have resided in Oregon continuously for the past six months. The Petitioner resides in The Respondent resides in 4. UCCJEA Information. The child/ren listed above has/have continuously resided in Oregon for the six months preceding the filing of this case. List the places where the minor child/ren of the parties has/have lived in the last five years and the names of the people they lived with at that time. Dates From/To County, State Parent(s)/Caretaker Current Address/ Contact Address of Parent/Caretaker Which Children Additional page attached; see section labeled "paragraph 4 continued." I have have not participated in any litigation concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following litigation: Name of Court State Case No. Date Result I do not know of any other domestic violence, custody, visitation, parenting time or placement proceeding involving the child/ren, or of any other court case which could affect this case, pending in this or any other state except for: (identify court, case number and the kind of proceeding) I do not know any person other than the other parent who has physical custody of the child/ren or who claims to have custody, visitation or parenting time rights except for (list name and address) 5. Parenting Plan (Custody and Parenting Time). Custody of the child/ren should be awarded as follows: Petitioner should be awarded sole custody of the following child/ren (list names): Respondent should be awarded sole custody of the following child/ren (list names): PETITION FOR CUSTODY AND PARENTING TIME - PAGE 2 of 7 Unmarried Parents-3A: Form 1 Petition for Custody 2010.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com  The parties have agreed to joint custody of the following child/ren (list names): Petitioner Respondent should have parenting time with the child/ren as set forth in the attached Parenting Plan, labeled Exhibit , or Other: Petitioner Respondent should not be granted parenting time because this would endanger the health and safety of the child/ren. State supporting facts: Parenting time should be supervised by Any cost of the supervision shall be paid by Petitioner Respondent Other: Petitioner and Respondent should each provide contact addresses and contact telephone numbers to the other and notify each other of any emergency circumstances or substantial changes in the child/ren's health. Petitioner should be allowed to move more than 60 miles further distant from the other parent without advance notice because good cause exists. 6. Child Support, including Health Care Coverage and Cash Medical Support. A. Other Pending Child Support Cases. (Check one.) No other agency or court child support proceeding is currently pending (include any child support matter being heard as part of a dissolution, separation, annulment, paternity, support or modification case). There is/are other child support proceeding(s) currently pending in either an agency or court case as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDER attached to this petition. B. Other Child Support Orders. (Check one.) No other child support orders, from an agency or court, are currently in effect in the State of Oregon or any other state. There is/are other child support orders from an agency or court as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDERS/JUDGMENTS attached to this petition. C. Currently Effective Child Support Order. (Check any that apply.) The following child support order/s is/are currently in effect: (List state, court/agency, case number, date of order) This order should remain in place and includes provisions for medical support for the child/ren, or This order is from an Oregon court or agency, one of the parents or the child/ren receiving support still resides in Oregon and the order should be changed because circumstances have changed since the last order was entered. State facts showing how circumstances have changed: PETITION FOR CUSTODY AND PARENTING TIME - PAGE 3 of 7 Unmarried Parents-3A: Form 1 Petition for Custody 2010.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com D. Cash Child Support. Complete either (1) or (2) below: (1) Cash child support should be paid by Petitioner to Respondent (or) Respondent to Petitioner beginning on the first or day of the month following the date of the judgment and continuing on the same day of each month thereafter. The total payment per month should be $ , which is the presumed correct amount as reflected on the child support guideline worksheets attached to this petition. Determined under the Oregon child support guidelines prior to judgment. The amount of support presumed correct under the guidelines would be unjust or inappropriate because . (The reasons must also be shown