IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: , Petitioner, and , Respondent. STATE OF ) ) ) ) ) ) ) ) Case No. PETITIONER’S AFFIDAVIT SUPPORTING JUDGMENT ) ) ss. ) County of , being first duly sworn, say: I am the petitioner in this proceeding. I, Respondent and I are the parents of the following minor child/ren: (name(s) and date(s) of birth) □ Respondent has not appeared in this matter and an Order of Default has been entered. □ Respondent filed a response and later □ signed and filed a Waiver of Further Appearance and Consent to Entry of Judgment, (or) □ has waived further hearing by stipulating to the terms of the Judgment. This case is now ready for a hearing on the merits. I make this affidavit in support of a Judgment without a hearing. The allegations in my Petition are true and it is just and reasonable that the relief requested be granted in the proposed judgment. □ Child custody or child support is involved in this case and at the time of filing: □ The child/ren had continuously resided in Oregon for six months before this case was filed. □ List any other basis for child custody jurisdiction The current residence of the minor child/ren is/are: Name of Child Resides With (Name, Address or Contact Address) For How Long □ Additional page attached, labeled “Information About Child/ren, Continued.” PETITIONER’S AFFIDAVIT SUPPORTING JUDGMENT - PAGE 1 OF 4 UnmarriedParents-3A: AffJudgment-3A-Ver03.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com □ Parenting time should not be ordered because my child/ren’s health or safety would be endangered because: □ I have good reason for the court to allow me to move more than 60 miles further distant from the other parent without giving written advance notice to the other parent. My good cause is: □ Child support is involved: Petitioner’s average gross monthly income is approximately $ Respondent’s average gross monthly income is approximately $ . Work or school related daycare is $ /month and is paid by □ Petitioner □ Respondent. The child support amount I have requested □ does not deviate from the amount presumed correct under per month because: Oregon Administrative Rules, or □ does deviate from the presumed amount of $ □ Child support is involved and Respondent does not live in Oregon. (If you checked the box above, check any of the following boxes that are true) □ Respondent was personally served with the petition in Oregon. □ Respondent lived in Oregon with the child. □ Respondent lived in Oregon and paid expenses for the birth or support of the child. □ The child was possibly conceived in Oregon. □ The child lives in Oregon because of the wishes of Respondent. □ Respondent and I both lived in Oregon at the same time (either together or separately) during the marriage for a period of six months, beginning (list dates) and ending on and less than one year has passed since respondent moved to a new residence out of state. □ Other basis for jurisdiction: □ A child support order currently exists and I requested that this court issue a new order because 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 the first order was entered. The changed circumstances are (explain what has changed since the last order): □ Petitioner has private health care coverage available to cover the child/ren at an out-of-pocket cost of $ per month for the child/ren’s portion of the coverage. □ This health care coverage should be ordered. □ Respondent has private health care coverage available to cover the child/ren at an out-of-pocket cost of $ per month for the child/ren’s portion of the coverage. □ This health care coverage should be ordered. □ Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren and, □ The custodial parent should be ordered to apply for and enroll the child/ren in public health care coverage. PETITIONER’S AFFIDAVIT SUPPORTING JUDGMENT - PAGE 2 OF 4 UnmarriedParents-3A: AffJudgment-3A-Ver03.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com □ Petitioner □ Respondent has already applied to enroll the child/ren in public health care coverage. This coverage should be maintained if the child/ren are accepted for enrollment. □ The child/ren are currently enrolled in public health care coverage. This coverage should be maintained. □ Petitioner should be ordered to provide appropriate private health care coverage when such coverage becomes available to him/her through any source. □ Respondent should be ordered to provide appropriate private health care coverage when such coverage becomes available to him/her through any source. □ Cash medical support should be ordered because: □ Neither party has appropriate private health care coverage available for the child/ren. □ The party receiving cash child support is also the party providing private health care coverage. The child support worksheet submitted with my judgment shows that cash medical support per month. should be $ □ Petitioner □ Respondent should pay, in addition to cash child support, cash medical support in the amount of $ per month. □ Cash medical support should not be ordered because: □ Petitioner □ Respondent has income that is no more than full-time Oregon minimum wage. □ Petitioner □ Respondent is eligible for Oregon public assistance. □ The parties should share the child/ren’s uninsured medical expenses as described below. □ Other reasons: □ Petitioner should pay % □ and Respondent should pay % of the uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND OPTICAL HEALTH costs incurred by the child/ren. This obligation should be □ in addition to □ instead of cash medical support. Note that if your judgment is by default, it cannot be different than what you asked for in your petition, unless the parties agree otherwise or unless circumstances have changed since your petition was filed. □ I request that personal information, such as telephone number, address and employment information, not be disclosed in the court’s judgment as otherwise required by ORS 25.020 and ORS 107.085 because my health, safety or liberty, or that of my child/ren would unreasonably be put at risk by such disclosure. State supporting facts: 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 form myself, and I completed it without paid assistance. □I paid or will pay money to for assistance in preparing this form. /// /// PETITIONER’S AFFIDAVIT SUPPORTING JUDGMENT - PAGE 3 OF 4 UnmarriedParents-3A: AffJudgment-3A-Ver03.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com Dated: , 20 . Petitioner’s 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 My Commission Expires: /Court Clerk I certify that this is a true copy: Petitioner’s Signature PETITIONER’S AFFIDAVIT SUPPORTING JUDGMENT - PAGE 4 OF 4 UnmarriedParents-3A: AffJudgment-3A-Ver03.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com