Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Petition For Custody And Parenting Time Under ORS 109.103 (3A) Form. This is a Oregon form and can be use in Circuit Court Statewide.
Loading PDF...
Tags: Petition For Custody And Parenting Time Under ORS 109.103 (3A), Oregon Statewide, Circuit Court
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)
)
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
Petitioner is the □mother □father and Respondent is the □mother □father of (names of children):
, born on the
following date/s:
1.
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)
, as
□ by administrative order docketed with the following court:
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 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)
///
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 1 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
3.
The minor child/ren reside/s in
The Petitioner resides in
The Respondent resides in
County, State of
County, State of
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 has/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
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:
□ Petitioner should be awarded sole custody of the following child/ren (list names):
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 2 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
□ Respondent 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):
□ Petitioner □ Respondent should have parenting time with the child/ren □ as set forth in the attached
, or □ Other:
Parenting Plan, labeled Exhibit
□ Petitioner □ Respondent 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 □ Petitioner □ Respondent □ Other:
□ Petitioner and Respondent 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, including Health Care Coverage and Cash Medical 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.
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 □ and includes provisions for medical support for the
child/ren, 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.
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 3 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
State facts showing how circumstances have changed:
D. Cash Child Support.
Complete either (1) or (2) below:
(1) □ Cash 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 judgment and continuing on the same day of each month thereafter. The total
, which is the presumed correct amount as
payment per month should be $
reflected on the child support guideline worksheets attached to this petition.
□ Determined under the Oregon child support guidelines prior to judgment.
□ The amount of support presumed correct under the guidelines would be unjust or
inappropriate because
.
(The reasons must also be shown on the support worksheets you attach to this petition.)
(2) □ 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:
E. Medical Support. Complete section (1) or (2) below. Also complete section (3) or (4) below.
Complete (1) or (2):
(1) 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 should be required to obtain and maintain this coverage throughout the period
of the support obligation for the benefit of the parties’ child/ren.
□ Health care coverage has already been ordered in another case as described in paragraph
D(2) above.
(2) 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
should be ordered to 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 should enroll the child/ren in public health care coverage.
□ The child/ren are currently enrolled in public health care coverage.
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 4 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Complete (3) or (4):
(3) Cash Medical Support Should Be 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, in addition to cash child
support □ Petitioner □ Respondent should pay $
for cash medical support
to □ Petitioner □ Respondent, or
□ Neither parent has appropriate private health care coverage available for the parties’
child/ren. □ Petitioner should pay cash medical support in the monthly amount of
$
to Respondent. □ Respondent should pay cash medical support in the
monthly amount of $
to Petitioner.
(4) Cash Medical Support Should Not Be Ordered.
□ Cash medical support should not be ordered for the following reasons:
□ The parent paying cash child support is also providing health care coverage.
□ Petitioner’s □ Respondent’s gross monthly income is at or below the Oregon
minimum wage for full-time employment or is eligible for Oregon public assistance.
□ I am requesting that the parties share the cost of the child/ren’s uninsured medical
expenses (see paragraph G. below).
□ Other reason:
□ 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). 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 □ Petitioner’s □ Respondent’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.
F.
RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES.
□ Petitioner should pay
% □ and Respondent should pay
% of the
reasonably incurred uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND
OPTICAL HEALTH costs incurred by the child/ren. □ This obligation is in addition to any
cash medical support ordered.
G.
LENGTH OF CHILD SUPPORT.
Unless the child becomes self-supporting, emancipated, or married:
□ The support ordered in paragraphs D., E., and F. for each child shall continue until the child
reaches eighteen (18) years of age.
///
///
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 5 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
□ The support ordered in paragraphs D., E.,and F. for each child shall continue until the child
reaches age 21 if the the child qualifies for support as a child attending school as defined by
Oregon Law.
H.
TAX DEPENDENTS. (Check one.)
□ 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 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
$
8.
Additional Provisions.
□ Additional page attached; labeled “Paragraph 8 Continued - Additional Provisions.”
9.
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
for the
of □ Petitioner □ Respondent or child/ren
following reasons:
□ Otherwise: (Fill out the information in the table below)
Petitioner
Respondent
Full 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).
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).
Former Legal Name(s)
Age
Address or Contact
Address
Telephone Number
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 6 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Petitioner
Respondent
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).
Employer Address
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 Telephone
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).
□ Additional page labeled “Paragraph 9 continued” attached.
10.
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: □ Petitioner □ Respondent
□ Both parties equally □ Other:
B.
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.
11.
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.
for assistance in preparing this form.
□ I paid or will pay money to
12.
Certificate of Residency.
I certify that the □ child resides or is found in, OR, □ one or both of the parties to this case currently
live/s in the county in which this petition is being filed.
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.
)
///
///
///
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 7 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
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
Address or Contact Address
Print Name
City, State, Zip
SIGNED AND SWORN to before me this
Telephone or Contact Telephone
day of
, 20
by
_________________________________________
Notary Public for ____________/Court Clerk
My Commission Expires: ____________________
I certify that this is a true copy.
_____________________________________
Petitioner, Signature
PETITION FOR CUSTODY AND PARENTING TIME - PAGE 8 of 8
Unmarried Parents-3A: Petition3AVer11.doc (9/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
