IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: ) ) ) ) and ) ) ________________________________, ) Respondent, ) and ) ) □ ________________________________, ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) ) ________________________________, Petitioner, Case No. ____________________ GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD 1. This matter came before the Court: □ On the motion and affidavit of Petitioner, the default of Respondent having been found. □ On the motion of Petitioner, the default of Respondent having been found, and Respondent being represented by a guardian ad litem or another person described in Rule 27. □ On the motion and affidavit of Petitioner, Respondent having filed a Waiver of Further Appearance. □ On the stipulations of the parties, as shown by the signatures below. □ 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 □ Affidavit and stipulations □ Evidence presented and found that: A. Children of the Parties. List names, dates of births, and ages. Name Date of Birth Age GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: American LegalNet, Inc. JURISDICTION AND MONEY AWARD - PAGE 1 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) www.FormsWorkflow.com B. 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 (i.e., the child/ren have lived here continuously for the six month period immediately before this case was filed). □ Other reason: □ Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because: C. Child/ren Who Are At Least 18 and Under 21 Years of Age. (child/ren’s name/s) is/are at least 18 and under 21 years of age, is unmarried and unemancipated and has: □ Waived further appearance in these proceedings. □ Signed and stipulated to the terms of judgment evidenced by the signature below. □ Fully participated in the proceedings and the judgment effectively binds him/her to the terms. NOW, THEREFORE, IT IS HEREBY ORDERED: The terms of this judgment are effective immediately. 1. Parenting Plan Custody of the child/ren is awarded as follows: □ Petitioner is awarded sole custody of the following child/ren (list names): □ Respondent is awarded sole custody of the following child/ren (list names): □ 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 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. GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: American LegalNet, Inc. JURISDICTION AND MONEY AWARD - PAGE 2 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) www.FormsWorkflow.com □ 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, including Cash Medical Support. Check either A or B below: (A) □ No child support shall be ordered at this time because: □ An order for child support in the amount of $ monthly, □ including health care coverage, has already been ordered and docketed with the County Circuit Court, case number □ Other reason: (B) □ Child support shall be paid by □ Petitioner to Respondent (or) □ Respondent to Petitioner beginning on the □ first or □ of the month following the date of the 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. Cash Medical Support: Of the amount ordered above in paragraph 2B, $ is cash medical. The cash medical support amount ordered is in addition to any percentage of uninsured costs either of the parties is ordered to pay below in paragraph 4(C). (Check if applicable) □ Neither Petitioner or Respondent have appropriate private or public health care coverage available for the parties’ child/ren (see 4(3) below). Cash medical support □ is □ is not ordered and the court’s findings in this regard are as follows: □ Petitioner □ Respondent and/or □ Child/ren are eligible for public medical assistance and cannot be ordered to pay cash medical support. (Check if applicable) □ This order shall modify and replace the following existing order: (list court/agency and case no.) 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. 3. Child Support Calculation (check any that apply). □ The child support worksheet on which the support amount was calculated is labeled “Exhibit " and attached to and incorporated in this judgment. □ The support award does not deviate from the amount presumed correct under the guidelines set out in the Oregon Administrative Rules. GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: American LegalNet, Inc. JURISDICTION AND MONEY AWARD - PAGE 3 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) www.FormsWorkflow.com □ 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 of (check one or more that apply): □ Recurring medical expenses of □ Other 4. Health Care Coverage. (DO NOT FILL THIS SECTION OUT if the boxes in Paragraph 2(A) above have been checked stating that there is an existing child support order that includes health care coverage currently in effect.) A.) PRIVATE INSURANCE IS AVAILABLE □ Petitioner □ Respondent shall name the child/ren as beneficiaries of the following appropriate private health care coverage for the duration of the support obligation (describe type/s of coverage): B.) NO PRIVATE INSURANCE IS AVAILABLE NOW Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren. 1.) □ Petitioner □ Respondent is ordered to apply to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 2.) □ Petitioner □ Respondent has already applied to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 3.) □ The child/ren are currently enrolled in public health care coverage. This coverage shall be maintained. 4.) □ Petitioner, □ Respondent □ Both Petitioner and Respondent are ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. C.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES □ Petitioner should pay % and Respondent should pay % of the uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is in addition to any cash medical support ordered above in paragraph 2 as part of the child support award. NOTICE ABOUT PERIODIC REVIEWS If you are receiving child support services through the Department of Justice pursuant to option (a) above, either parent may request that the Department of Justice/Division of Child Support review the amount of support ordered after three years from the date the order took effect or at any time upon a substantial change of circumstances. 5. 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 there is proof of timely payment of previously-ordered support and income withholding would not be in the best interests of the child. GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 4 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com 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 or □ by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). (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. NOTICE OF INCOME WITHHOLDING This child 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 withholding. Exceptions may apply in some circumstances. 6. Dependents for Tax Purposes. □ Petitioner □ Respondent shall be entitled to claim the following child(ren) as dependent(s) for tax purposes beginning the year this judgment is entered (list names): , OR □ Other (specify): 7. The support obligations ordered in paragraphs 2 through 6 above shall continue until the child reaches 18years of age or is otherwise emancipated, or until the child reaches age 21, so long as the child is a student attending school, as defined by Oregon law. 8. Life Insurance Coverage for Child/ren. □ Petitioner □ Respondent shall obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $ . /// /// /// /// /// /// /// /// /// /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 5 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com 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 1-800-850-0228 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 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 three 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. 9. Additional Provisions: □ Additional page attached labeled “Paragraph 9 - Additional Provisions continued”. 10. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service was completed by the Sheriff) that were deferred (required to be paid at a later date) by the court shall be paid by: □ Petitioner □ Respondent. □ Both parties equally □ Other: . /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 6 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com B. Costs and Fees Paid by the Parties □ Each party shall be responsible for paying his/her own court costs and service fees for this case. □ To be paid by both parties equally □ Petitioner □ Respondent shall reimburse the other spouse for his/her court costs and service fees for this case. Other: Judgment shall be entered according to the cost and fee allocation listed above. 11. Information Required by ORS 25.020. □ Based on a finding that the health, safety, or liberty of □ Petitioner □ Respondent or a child/ren would unreasonably be put at risk by disclosure of the following information, □ Petitioner □ Respondent has been allowed not to disclose this information. □ Otherwise: (Fill in the blanks in the table below.) Petitioner Respondent Address or Contact Address Telephone Number Social Security Number Do not list. Provided by UTCR 2.100 Do not list. Provided by UTCR 2.100 Affidavit Affidavit Drivers License Number Employer Name Employer Address Employer Telephone □ Additional page labeled “Paragraph 11 continued” attached. Both parties shall inform the Court and the Department of Justice (P.O. Box 14506, Salem, Oregon 97309) in writing of any change in the above information required by ORS 25.020 within ten (10) days of such change, unless a finding of unreasonable risk has been made in this case. If the court has ordered that a party be allowed not to disclose information by means of this Judgment in Paragraph 17 above, the Department of Justice or the District Attorney shall not disclose the information in the preceding section to the other parent. 12. Money Award. Child Support Obligation □included □not included. JUDGMENT CREDITOR (This is the party receiving payment from Judgment Debtor) □ Petitioner □ Respondent JUDGMENT DEBTOR (This is the party required to pay Judgment Creditor) □ Petitioner □ Respondent Full Name Address or Contact Address GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 7 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com . Attorney’s Name, Telephone Number and Address The following information is required ONLY for the party designated as the “Judgment Debtor” above. Date of Birth Social Security Number Do not list. Provided by UTCR 2.100 Affidavit Do not list. Provided by UTCR 2.100 Affidavit Driver’s License Number and State of Issuance The following information is to be provided by the party designated as the “Judgment Creditor” above. Others Entitled to Portions of Judgment The following person(s) or public bod(ies) are known by judgment creditor to be entitled to a portion of a payment made on the judgment (other than the judgment creditor’s attorney): □ None or □ Type of Judgment Child Support Award Amount of Judgment WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Prejudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) WHO PAYS □ Petitioner 1. $ □ Other: the judgment □ per month or □ Other: , starting on the □ first day or of the month following the date of □ Of this Child Support Award, $ ________________ constitutes “cash medical support” $___________________________________________ □ Respondent WHO RECEIVES □ Petitioner $___________________________________________ □ Respondent Postjudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) WHO PAYS □ Petitioner Nine percent (9 %) per annum simple interest on the unpaid balance of the total judgment amount(s) of □ Respondent WHO RECEIVES □ Petitioner $ . Interest accrues from the date the judgment is entered and continues until fully paid. □ Respondent GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 8 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com Accrued Arrears (if any, on judgments to be paid on a periodic basis) WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees) WHO PAYS □ Petitioner 1. $ per month, starting on the □ first day or □ Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date). $___________________________________________ □ Respondent WHO RECEIVES □ Petitioner $___________________________________________ □ Respondent Attorneys Fees (if any) WHO PAYS □ Petitioner $___________________________________________ □ Respondent WHO RECEIVES □ Petitioner $___________________________________________ □ Respondent DATED this ________ day of ________________________________, 20______. Circuit Court Judge Print Name APPLICATION FOR FULL CHILD SUPPORT PROGRAM SERVICES: By signing below, I apply for child support services, including enforcement, from the Child Support Program(CSP). Check the box in Paragraph 5(a) if you are requesting accounting and disbursement services only. (Note: If you never received TANF, tribal TANF or AFDC in any state, an annual $25 fee will apply if over $500 is collected and distributed to the family each year.) □Petitioner, Signature Date □Respondent, Signature Date GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 9 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com □ All parties have agreed (stipulated) to the terms of this judgment. Sign before a Notary Public or Court Clerk only. Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on of , 20 by , (date) (name of person). Notary Public for My Commission Expires: /Court Clerk of , (date) Respondent, Signature State of County of ) ) This instrument was acknowledged before me on , 20 by (name of person). Notary Public for My Commission Expires: /Court Clerk /// /// /// /// /// /// /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 10 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com □If applicable, child who is at least 18 and under 21 years of age, has agreed (stipulated to the terms of this judgment: (sign only your name) Child, Signature State of County of ) ) This instrument was acknowledged before me on of , 20 by , (date) (name of person). Notary Public for My Commission Expires: /Court Clerk 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 Address or Contact Address Telephone or Contact Telephone City, State, Zip Certificate of Mailing. I certify that I mailed a copy of this judgment and attachments thereto by U.S. Mail with postage paid to the other party at the following address: on the following date: . □ Petitioner □ Respondent, Signature Print Name I certify that this is a true copy: □ Petitioner □ Respondent, Signature GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 11 of 11 Unmarried Parents-3A: Judgment3AVer09 (1/08) American LegalNet, Inc. www.FormsWorkflow.com