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 which the following persons were present: □ At a hearing held (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: JURISDICTION AND MONEY AWARD - PAGE 1 of 12 American LegalNet, Inc. Unmarried Parents-3A: Judgment3AVer10.doc (9/10) 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, 19, or 20 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: JURISDICTION AND MONEY AWARD - PAGE 2 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) □ 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. Cash Child Support. Complete either (a) or (b) below: (a) □ Cash child support must 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 total payment per month is $ for children. The cash child support: □ Is the amount presumed to be appropriate under the support guidelines. □ Is different from the presumed appropriate amount of $ reasons) (b) because (list □ No cash child support is ordered in this judgment because: □ An order, □ including medical support, for child support in the monthly amount of has already been ordered in Circuit Court case number $ in County, Oregon. □ Other reason: 3. Medical Support. Complete section (a) or (b) below. Also complete section (c) or (d) below. Complete (a) or (b): (a) Private Health Care Coverage is Appropriate and Available. □ Petitioner □ Respondent □ Both Petitioner and Respondent has/have appropriate private health care coverage available for the parties’ child/ren through an employer, spouse, domestic partner or other source. □ Petitioner □ Respondent □ Both Petitioner and Respondent is/are ordered to obtain and/or maintain this coverage throughout the period of the support obligation for the benefit of the parties’ child/ren. □ Health care coverage is not ordered in this judgment because it has already been ordered in another case as described in section 2(b) above. (b) No Private Health Care Coverage is Appropriate or Available. □ Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren. □ Petitioner □ Respondent □ Both Petitioner and Respondent must provide appropriate private health care coverage for the child/ren when such coverage becomes available to them at a reasonable cost through any source. □ The custodial parent shall enroll or maintain the child/ren in public health care coverage. GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 3 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) . Complete (c) or (d): (c) Cash Medical Support Ordered. □ Because the parent receiving cash child support is ordered to maintain private health care coverage and the parent paying cash child support is not ordered to maintain private health insurance, in addition to cash child support □ Petitioner □ Respondent must pay $ for cash medical support to □ Petitioner □ Respondent. □ Because neither parent has appropriate private health care coverage available for the parties’ child/ren: □ Petitioner must pay cash medical support in the monthly amount of $ to Respondent and/or □ Respondent must pay cash medical support in the monthly amount of $ to Petitioner. (d) Cash Medical Support Not Ordered. □ Cash medical support is not ordered for the following reasons: □ The parent paying cash child support is also providing health care coverage. □ Section (e) below requires the parties to share the cost of the child/ren’s uninsured medical expenses. □ Petitioner’s □ Respondent’s gross monthly income is at or below the Oregon minimum wage for full-time employment. □ Other reason: (e) Responsibility for Uninsured Health Expenses. After the custodial parent pays the first $250 per year per child, □ Petitioner must pay % and Respondent must pay % of the reasonably incurred uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is □ in addition to □ instead of any cash medical support ordered above in paragraph 2 as part of the child support award. 4. Length of Child Support. Unless the child becomes self-supporting, emancipated, or married: □ The support ordered in paragraphs 2 and 3 above for each child shall continue until the child reaches eighteen (18) years of age. □ The support ordered in paragraphs 2 and 3 above for each child shall continue until the child reaches age 21 if the child qualifies for support as a child attending school as defined by Oregon law. 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. /// /// /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 4 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) 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. 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. 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 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) 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. 8. Additional Provisions: □ Additional page attached labeled “Paragraph 8 - Additional Provisions continued”. 9. 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: 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. 10. Information Required by ORS 25.020 and ORS 107.085. □ Based on a finding that the health, safety, or liberty of □ Petitioner □ Respondent or a child, , would unreasonably be put at risk by disclosure of the following information, □ Petitioner □ Respondent has been allowed not to disclose this information. 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 below 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 GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 6 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) . allowed not to disclose information, the Department of Justice or the District Attorney shall not disclose the information in the following section to the other parent. □ Otherwise: Petitioner Respondent Full Name Former Legal Name(s) Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Age Address or Contact Address Telephone Number Social Security Number Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Driver License Number Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Employer Name Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Employer Address Employer Telephone □ Additional page labeled “Paragraph 10 - Required Information continued” attached. Date of marriage/domestic partnership: Place of marriage/domestic partnership: . . 11. Money Award. Child Support Obligation □ included □ not included. Additional information 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 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) Attorney’s Name, Telephone Number and Address (if applicable) Year of Birth Last Four Digits of Driver License Number and State of Issuance Last Four Digits of the Support Obligor’s Social Security Number The following information is to be provided by any party entitled to receive a money award (a “judgment creditor”) as listed in this Judgment. Others Entitled to Portions of Judgment Payable to PETITIONER The following person(s) or public bod(ies) are known by Petitioner to be entitled to a portion of a payment made on the judgment (other than Petitioner’s attorney): □ None or □ Others Entitled to Portions of Judgment Payable to RESPONDENT The following person(s) or public bod(ies) are known by Respondent to be entitled to a portion of a payment made on the judgment (other than the Respondent’s attorney): □ None or □ Type of Judgment Child Support Award Amount of Judgment WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Property Division (if applicable) WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent □ per month, of which $ $ is cash medical support. Starting on □ the first day or (day) month following the date of the judgment of the per month or starting on □ the first 1. $ day or of the month following the date of □ Other: the judgment, lasting until (date) , or the death of either party, whichever comes first; or 2. A lump sum payment of $ by (date): to be paid GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 8 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) Prejudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Postjudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Accrued Arrears (if any, on judgments to be paid on a periodic basis) Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees) Attorneys Fees (if any) WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent Nine percent ( 9 %) per annum simple interest on the unpaid balance of the total judgment amount(s) of . Interest accrues from the date the $ judgment is entered and continues until fully paid. WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent 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 $ (date). to be paid by: WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 9 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) 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 4(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 □ 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 Respondent, Signature /// /// /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 10 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) State of County of ) ) This instrument was acknowledged before me on of , 20 , (date) (name of person). by Notary Public for My Commission Expires: /Court Clerk □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 /// /// /// GENERAL JUDGMENT OF CUSTODY AND PARENTING TIME □ and SUPPORT □ ORDER RE: JURISDICTION AND MONEY AWARD - PAGE 11 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10) 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 12 of 12 American LegalNet, Inc. www.FormsWorkFlow.com Unmarried Parents-3A: Judgment3AVer10.doc (9/10)