IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _________________ In the Matter of □ the Marriage of: ________________________________, Petitioner, and ________________________________, Respondent. STATE OF ______________________ County of _______________________ ) ) ) ) ) ) ) ) Case No. ______________________ □ PETITIONER’S □ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT RE: □ CUSTODY □ PARENTING TIME □ CHILD SUPPORT ) ) ss. ) I, □ Petitioner □ Respondent, being first duly sworn, say that the following is true: I make this affidavit to respond to the motion to modify that has been filed. 1. □ I disagree with the following request(s) made by the other party to: a. □ Change custody of the minor child/ren because: b. □ Change the current court-ordered parenting time because: c. □ Terminate □ Petitioner’s □ Respondent’s child support obligation due to the requested change in custody because: d. □ Require □ Petitioner □ Respondent to pay cash child support in the amount of $ per month beginning , 20 , because: e. Require □ Petitioner and/or □ Respondent to maintain the following private health care coverage throughout the period of the support obligation for the benefit of the parties’ child/ren (describe type/s of coverage): because: □ PETITIONER’S □ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT Page 1 of 4 American LegalNet, Inc. Modification-4B: Response4BVer06.doc (9/10) www.FormsWorkFlow.com f. Require □ Petitioner □ Respondent □ Both Petitioner and Respondent to apply for and enroll the child/ren in public health care coverage if they are not currently enrolled because: □ and that public health care coverage should be maintained if the child/ren are currently enrolled or accepted for enrollment because: g. Require □ Petitioner □ Respondent □ Both Petitioner and Respondent to provide appropriate private health care coverage when such coverage becomes available to them through any source because: h. Require □ Petitioner to pay % □ and Respondent to pay % of the uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND OPTICAL HEALTH costs incurred by the child/ren because: i. □ Require □ Petitioner □ Respondent to obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation because: j. Require □ Petitioner □ Respondent □ Both Petitioner and Respondent to pay cash medical support to the other because: k. That court costs and service fees be paid by □ Petitioner □ Respondent □ Other □ Each Party be responsible for paying his or her own court costs and services fees because: l. because: 2. Other: I would agree to the following orders: 3. Information Required by the Uniform Child Custody Jurisdiction and Enforcement Act. List the places where the minor child/ren of the parties have lived in the last five years and the names of the people they lived with at that time. Dates County, State Parent(s)/Caretaker Current Address/Contact Address of Parent/Caretaker Which Children □ PETITIONER’S □ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT Page 2 of 4 American LegalNet, Inc. Modification-4B: Response4BVer06.doc (9/10) www.FormsWorkFlow.com Dates County, State Parent(s)/Caretaker Current Address/Contact Address of Parent/Caretaker Which Children □ Additional page attached; see section labeled “UCCJEA Information 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 agency proceeding or court case which could affect this case, previously filed or currently pending in this or any other state □ except for: (identify agency or court, case number, date filed, and kind of proceeding) I do not know any person other than petitioner 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) 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. □ Petitioner □ Respondent, Signature Address or Contact Address Print Name City, State, Zip Telephone or Contact Telephone SIGNED AND SWORN to before me this ___________ day of _______________, 20 _____. ____________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ □ PETITIONER’S □ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT Page 3 of 4 American LegalNet, Inc. Modification-4B: Response4BVer06.doc (9/10) www.FormsWorkFlow.com I certify that this is a true copy.____________________________________ □ Petitioner □ Respondent, Signature □ PETITIONER’S □ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT Page 4 of 4 American LegalNet, Inc. Modification-4B: Response4BVer06.doc (9/10) www.FormsWorkFlow.com