IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _________________ 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) 1. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 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 __________________________________ is the mother and ______________________________ is the father of (names of children): ____________________________________________________________________ ____________________________, born on the following date(s): ______________________________________. 2. 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: (list name(s) of child/ren involved) ‘ by judicial order entered in the following court: : , as case Page 1 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 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) 3. The minor child/ren reside(s) in ______________________________ County, State of _______________. The petitioner resides in _______________________________ County, State of ______________________. The respondent resides in _______________________________ County, State of _______________________. 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 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 Page 2 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com /// 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: ‘ Mother should be awarded sole custody of the following child/ren (list names): ‘ Father should be awarded sole custody of the following child/ren (list names): ‘ The parties have agreed to joint custody of the following child/ren (list names): , ‘ Father ‘ Mother should have parenting time with the child/ren ‘ as set forth in the attached Parenting Plan, labeled Exhibit , or ‘ Other: ‘ Father ‘ Mother 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 ‘ Father ‘ Mother ‘ Other: ‘ Mother and Father 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. 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. Page 3 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com /// 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, 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 supporting facts: ‘ The following child support proceeding has been started but is not yet resolved (an order has not yet been issued): _______________________________________________________________________________ (list court/agency, and case number) D. Child Support in this Case. ‘ No child support should be ordered in this case because: ‘ Child support in the amount of $ __________ monthly has already been ordered and docketed with the following court (list county and state):_____________________________________________________________. ‘ Other reason: _________________________________________________________________ _______________________________________________________________________________. ‘ Child support should be paid by ‘ Mother to Father (or) ‘ Father to Mother beginning on the first day of the month following the date of the judgment and continuing on the first (1st) day of each month thereafter. Under the Support Guidelines set out in Oregon’s Administrative Rules, the total payment of child support per month should be: “$ for children, “ as reflected in the attached Worksheets, or “ determined prior to judgment. If a specific amount is indicated above, that amount: ‘ does not deviate from the amount presumed correct under the guidelines. Page 4 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com ‘ does deviate from the amount presumed correct under these guidelines because: . ‘ All payments of child support should be made to the Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 ‘ by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). Petitioner requests that collection, accounting, disbursement, and enforcement services be provided by the Department of Justice. In addition, support for a child attending school (between the ages of 18 and 21) as defined by Oregon law shall be distributed by the Department of Justice directly to the child subject to ORS 107.108. ‘ (Applies only if support enforcement services are not being provided.) Petitioner requests an exception to the income withholding requirement of ORS 25.378 allowing payment to be made directly to ‘ Father’s ‘ Mother’s checking or savings account. A receipt of deposit should be kept by the parent paying support as proof of payment. The parent receiving support should provide the paying parent with current deposit slips and/or bank name, account name, and account number. E. (Check one.) ‘ Father ‘ Mother 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): F. The support payments for each child should continue until the child reaches 18 years 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. 7. Life Insurance Coverage for Child/ren. ‘ Father ‘ Mother should obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation. The coverage should be in the amount of $_____________. Page 5 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 8. Medical Insurance Coverage for Child/ren. Throughout the period of the support obligation, ‘ Father ‘ Mother should name the child/ren as beneficiaries of any health, accident, dental, orthodontic, and optical insurance plan, available through that parent’s employment, group, or union, and is accessible to the children at a reasonable cost that doesn’t make the application of the guidelines unjust or inappropriate. If that parent fails to maintain insurance under these circumstances for the child/ren, that parent should be responsible for any of those expenses incurred after the date of the court order requiring the coverage. If that parent maintains this insurance but the insurance does not provide complete coverage, that parent should 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 the final judgment is entered, that parent should provide insurance in the future when it becomes available to him/her. Whenever ‘ Father ‘ Mother does not have health, accident, dental, orthodontic, or optical insurance available through employment, group or union membership, that parent should pay ______% of the uninsured costs incurred by the child/ren throughout that period, including costs for prescriptions. 9. Additional Provisions. ‘ Additional page attached; labeled “Paragraph 9 Continued - Additional Provisions.” 10. Information Required by ORS 25.020 and ORS 107.085. ‘ Disclosure of the following information would unreasonably put to risk the health, safety, or liberty of ‘ Mother ‘ Father or a child for the following reasons: . ‘ Otherwise: (Fill out the information in the table below) Mother Father Full Name Former Legal Name(s) Age Address or Contact Address Page 6 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com Mother Father Telephone Number Social Security Number Do not list. Provide by UTCR 2.100 Affidavit Do not list. Provide by UTCR 2.100 Affidavit Drivers License Number Employer Name Employer Address Employer Telephone ‘ Additional page labeled “Paragraph 10 continued” attached. 11. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service completed by the Sheriff) that are deferred (required to be paid at a later date) by the court should be paid by: ‘ Both parties equally B. ‘ Petitioner ‘ Respondent ‘ Other: Costs and Fees Paid by the Parties ‘ Each party should be responsible for paying his or her own court costs and service fees for this case. ‘ To be paid by both parties equally ‘ Petitioner ‘ Respondent should reimburse the other party for his or her court costs and service fees for this case. ‘ Other: Judgment should be entered according to the cost and fee allocation listed above. 12. 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. 13. Certificate of Residency. I certify that one or both of the parties to this case currently live in the county in which this petition is being filed. Page 7 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com WHEREFORE, petitioner requests a Judgment granting the relief asked for above, and other equitable relief that the Court thinks is just. STATE OF ______________________ County of ________________________ ) ) ss. ) I, _________________________________, being duly sworn, say that I am the petitioner in this matter and that the foregoing petition is true and correct to the best of my knowledge. ____________________________________________________________________________________________ Petitioner, Signature Print Name ___________________________________________________________________________________________ Address or Contact Address City, State, Zip Telephone or Contact Telephone SIGNED AND SWORN to before me this ___________ day of _________________________, 20_____, by _____________________________________. _________________________________________ Notary Public for ____________/Court Clerk My Commission Expires: ____________________ I certify that this is a true copy. _____________________________________ Petitioner, Signature Page 8 of 8, PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 ‘ and CHILD SUPPORT UnmarriedParents-3A: Petition3AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com