Form 11 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN IN THE MATTER OF “ THE MARRIAGE OF “ SEPARATION OF “ CUSTODY OF ___________________________________, Petitioner, and ___________________________________, Respondent. 1. ) ) ) ) ) ) ) ) ) ) ) Case No. ______________________ SUPPLEMENTAL JUDGMENT MODIFYING “ CUSTODY “ PARENTING TIME “ CHILD SUPPORT “ ORDER RE: JURISDICTION “ STIPULATED [ORS 107.174] This matter came before the Court: a. “ On the motion and affidavit of “ Petitioner / “ Respondent, the default of “ Petitioner / “ Respondent having been found. b. “ On the motion and affidavit of “ Petitioner / “ Respondent; “ Petitioner / “ Respondent having filed a Waiver of Further Appearance. c. “ On the stipulations of the parties, as shown by the signatures below. d. “ At a hearing held ______________________, at which the following persons were present: (Date) “ Petitioner “ Petitioner’s attorney “ Respondent “ Respondent’s attorney 2. Findings. The Court considered the: “ Affidavit “ Stipulations “ Evidence presented and found that: a. Child Custody Jurisdiction. (Check appropriate boxes) “ Oregon has jurisdiction under the Uniform Child Custody Jurisdiction and Enforcement Act to hear the “ custody “ parenting time issue because: “ Oregon is the child/ren’s home state (lived here continuously for the last six months). “ Other reason: _____________________________________________________________________ ___________________________________________________________________________________ “ Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because: ___________________________________________________________________________________ ___________________________________________________________________________________ b. “ CUSTODY. A substantial change in circumstance has occurred since the last custody order and it would be in the child/ren’s best interests to change the custody terms. c. “ PARENTING TIME. It would be in the child/ren’s best interests to change the parenting time terms d. “ CHILD SUPPORT. A change in custody or parenting time has occurred requiring a change in the current support obligation. Page 1 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com IT IS THEREFORE ORDERED that: The Judgment is modified as follows: 1. Custody: a. “ Petitioner “ Respondent is awarded sole custody of the child/ren________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ (Full Names and dates of birth) “ The parties have agreed to joint custody of the following child/ren: _________________________________________________________________________________________________ “ Physical custody of the child(ren) named below to: “ Petitioner ________________________________________________________________________________ “ Respondent_______________________________________________________________________________ “ Joint ____________________________________________________________________________________ Parenting Time: “ Petitioner “ Respondent shall have parenting time with the child/ren in accordance with “ the attached Standard Linn County Parenting Plan, or “ the attached parenting plan, labeled “Exhibit 1”. OR “ Petitioner “ Respondent shall have reasonable parenting time with the child/ren upon giving reasonable notice to the other parent. Minimum parenting time, in case of disagreement, shall be: _____________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ “ Additional page(s) attached, labeled “Exhibit 1 .” “ Petitioner “ Respondent shall not have parenting time because this would endanger the health and safety of the child/ren. “ Parenting time shall be supervised by _____________________________________________. “ Any cost of the supervision shall be paid by “ Petitioner “ Respondent “ Other:_________________________ “ Petitioner and Respondent shall 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. Neither parent shall move to a residence more than 60 miles further distant from the other parent without giving the other parent reasonable notice of the change of residence and providing a copy of such notice to the court, or “ the requirement of ORS 107.159 regarding notice of move is suspended for good cause found. 2. Child Support: a. “ The Judgment is modified to terminate “ Petitioner’s “ Respondent’s support obligation effective for the child/ren: __________________________________________________________________________ ________________________________________________________________________________________________________ (name(s) and date(s) of birth) due to the change in custody. b. “ 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 Supplemental Judgment and continuing on the same day of each month thereafter. The support for each child shall continue until the child reaches eighteen (18) years of age, or is otherwise emancipated, unless the child is a student attending school as defined by Oregon law, in which case support shall continue until the child reaches 21 years of age. Until further order, the total payment per month shall be $___________________ for _____________ children. c. “ This order shall modify and replace the following existing order:____________________________________ ___________________________________________________________________________________________ (list court/agency and case no.) Page 2 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com d. e. because the court finds that the existing order was issued by an Oregon court or agency, one of the parents or the child/ren receiving support under the order still resides in Oregon and circumstances have changed since this order was entered. Child Support Calculation. “ The child support worksheet on which the support amount was calculated is labeled “Exhibit ____" and attached to and incorporated in this Supplemental Judgment. “ The support award does not deviate from the amount presumed correct under the guidelines set out in the Oregon Administrative Rules. “ The support amount presumed correct under the guidelines set out in Oregon Administrative Rules is $___________. The support award deviates from this amount because this Court finds that application of the formula would be unjust or inappropriate in this case because _________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Payment of Child Support. Pursuant to ORS 25.378(1), an income withholding order shall be issued to enforce the child support obligation unless an exception is indicated below. “ Exceptions to withholding. Income withholding is not ordered at this time because there is no support arrearage, the paying parent has not previously been granted an exemption from withholding, and: “ The parents, and the State, if support rights are assigned, have agreed in writing to an alternative arrangement; or “ Good cause not to require withholding is found because ____________________________ __________________________________________________________________________________________. All payments of child support shall be made (check either (a) or (b) below): (a) “ To the Oregon Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309. By petitioner’s request, collection, accounting disbursement, and enforcement services of this obligation shall be through the State of Oregon’s Department of Justice. (b) “ Pursuant to the above exception, directly to “ Petitioner's “ Respondent’s checking or savings account. A receipt of deposit shall be kept by the parent paying support as proof of payment. A canceled check is also prima facie evidence that payment has been made. The person receiving support shall provide the paying parent with current deposit slips and/or bank name, account name and account number. /// /// /// /// /// /// /// Page 3 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com NOTICE OF INCOME WITHHOLDING This support order is enforceable by income withholding under ORS 25.378 to 25.390, 25.414 to 25.372 and 25.375. Withholding shall occur immediately, whenever there is an arrearage at least equal to the support payment for one month, whenever the obligated parent requests such withholding, or whenever the obligee requests withholding for good cause. The District Attorney or, as appropriate, the Division of Child Support of the Department of Justice will assist in securing such NOTICE ABOUT PERIODIC REVIEW AND MODIFICATION OF CHILD SUPPORT ORDERS If your child support case is handled by the District Attorney or the Department of Justice Division of Child Support, this agency will review your child support order if at least two years have passed since the order was entered, modified, or last reviewed. This review will take place only if a parent requests. The purpose of the review is to see if the amount ordered is still within the guidelines for child support set out in Oregon law. The review could result in an increase or decrease in the support amount, depending on the parents’ financial circumstances and the needs of the child. This “periodic review” service is provided at no cost to parents, but is available only for cases handled by the District Attorney or the Department of Justice. The support agency handling your case will also review your support order for compliance with the guidelines whenever a substantial change in circumstance has occurred. You can request this “change in circumstance” modification from the support agency. But any support order (not just orders handled by the District Attorney or Department of Justice) can be modified because of a change in circumstance, so a private attorney is able to assist you with this, too. You may also represent yourself. NOTICE ABOUT PARENTING TIME AND CHILD SUPPORT The terms of child support and parenting time (visitation) are designed for the child’s benefit and not the parents’ benefit. You must pay support even if you are not receiving parenting time. You must comply with parenting time and visitation orders even if you are not receiving child support. Violation of child support orders and visitation or parenting time orders is punishable by fine, imprisonment or other penalties. Publicly funded help is available to establish, enforce, and modify child support orders. Paternity establishment services are also available. Contact your local district attorney, the domestic relations court clerk, or the Department of Justice at 1-800850-0228 or 503-378-5567 for information. Publicly funded help may be available to establish, enforce, and modify parenting time or visitation orders. Forms are available to enforce parenting time or visitation orders. Contact the domestic relations, civil court clerk or courthouse facilitator for information. NOTICE OF CHANGE OF STATUS OF THE CHILD The custodial parent shall notify the parent paying child support when that child receives income for his or her own gainful employment, is married or enters the military service during the period when the parent is required to contribute to the support of the child. ORS 107.415 Page 4 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com 3. 4. Life Insurance Coverage for Child/ren. “ No change. “ Petitioner “ Respondent shall obtain and maintain life insurance for the benefit of the child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $_____________________. “ Husband “ Wife will not obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation because ______________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Medical Insurance Coverage for Child/ren. “ No change. Throughout the period of the support obligation, ‘Petitioner ‘Respondent shall name the child/ren as beneficiaries of any health, accident, dental, orthodontic, and optical insurance plan, available through this parent’s employment, group, or union, that is accessible to the children. If this parent fails to maintain insurance under these circumstances for the child/ren, this parent shall be responsible for any of those expenses incurred after the date of the court order requiring the coverage. If this parent maintains this insurance but the insurance does not provide complete coverage, this parent shall pay ______% of the uninsured costs. If the insurance coverage for the child/ren is provided through the parent’s employment, group, or union, and if this employment, group or union membership is then terminated, this parent shall notify the other parent of this fact prior to or immediately upon termination. If insurance is not available to this parent when this judgment is entered, this parent shall provide insurance in the future when it becomes available to him/her. Whenever ‘Petitioner ‘Respondent does not have health, accident, dental, orthodontic, or optical insurance available through employment, group or union membership, this parent shall pay ______% of the uninsured costs incurred by the child/ren throughout that period, including costs for prescriptions. Petitioner Respondent Full Name Former Legal Name(s) Address or Contact Address Telephone Number /// /// /// /// /// /// /// Page 5 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com MONEY AWARD Child Support Obligation “ included “ not included. 5. Petitioner Respondent Full Name Address or Contact Address Attorney’s Name, Telephone Number and Address The following information is only required if parent is listed as judgment debtor below. Date of Birth Social Security Number Please provide your Social Security number on the UTCR 2.100 Form only Please provide your Social Security number on the UTCR 2.100 Form only Driver’s License Number and State of Issuance The following person(s) or public bod(ies) are known by (either) judgment creditor to be entitled to a portion of a payment made out of the judgment (other than the judgment debtor’s attorney): ___________________________________________________ _______________________________________________________________________________________________________ Type of Creditor (to receive payment from debtor) Debtor (required to pay) Amount of Child Support per month Court Costs Service Fees Attorney Fees Other: /// /// /// /// /// /// Page 6 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com Interest accrues on all judgments at 9% per annum, simple interest from the date the Supplemental Judgment is entered. For purposes of child support interest accrues on each unpaid installment as it becomes due on the first day of each month. Monthly payments begin the day of the month following the date the is signed. DATED this ________ day of ________________________________, 20______. _______________________________________________ Circuit Court Judge _______________________________________________ Print Name “ Both parties have agreed (stipulated) to the terms of this : (both parties must sign below) ________________________________ __________ Petitioner Signature Date _________________________________ ___________ Respondent Signature Date 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. Submitted by: ____________________________________________________________________________________________________ “ Petitioner “ Respondent Signature Print Name Date ____________________________________________________________________________________________________ Address or Contact Address City, State, Zip Telephone or Contact Telephone I certify that this is a true copy: ____________________________________ “ Petitioner “ Respondent, Signature Page 7 of 7, SUPPLEMENTAL JUDGMENT MODIFYING CUSTODY, PARENTING TIME, AND SUPPORT LINN CO UNTY FORM Modificat ion-4A: Form 11 Supplemental Judgment M odifying Custody, Parenting Time, and Support.wpd (4/06) American LegalNet, Inc. www.FormsWorkflow.com