IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of □ the Marriage of: ________________________________, Petitioner, and ________________________________, Respondent. 1. ) ) ) ) ) ) ) ) ) ) Case No. RESPONSE □ and COUNTERCLAIM DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 CLAIM □ SUBJECT □ NOT SUBJECT TO MANDATORY ARBITRATION Respondent appears and agrees with the petition for separation filed in this case, except paragraph(s): □ Additional page attached labeled “Paragraph 1, continued.” 2. Respondent makes the following counterclaim(s): (a) (b) □ Additional page attached labeled “Counterclaims, continued”. 3. Child Support: □ Social Security or apportioned Veterans’ benefits are paid to or on behalf of the child[ren] in the amounts listed below as a result of my disability or retirement, and I request that child support be reduced dollar for dollar. Child’s Name: Amount of Benefit received by child: $ Child’s Name: Amount of Benefit received by child: $ Child’s Name: Amount of Benefit received by child: $ /// /// /// RESPONSE □ and COUNTERCLAIM – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER American LegalNet, Inc. ORS 21.111 (WITH UCCJEA INFORMATION) - PAGE 1 OF 3 www.FormsWorkflow.com Separation-2C: Response2CVer03.doc (2/08) □ Survivors’ and Dependents’ Educational Assistance under 38 USC chapter 35 is paid to or on behalf of the child[ren] in the amounts listed below as a result of my disability or retirement, and child support must be reduced dollar for dollar. Child’s Name: Amount of monthly assistance received: $ Child’s Name: Amount of monthly assistance received: $ Child’s Name: Amount of monthly assistance received: $ 4. (Optional) Exception to Income Withholding of Child Support: Respondent requests an exception to the income withholding requirement of ORS 25.378 as follows: □ Allowing payment to be made by electronic funds transfer (EFT) to the Department of Justice (this option is the only one permitted if support enforcement services are being provided to either party). □ Allowing payment to be made directly to □ Petitioner’s □ Respondent’s checking or savings account (this option is allowed only if support enforcement services are not being provided to either party). 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. State facts in support of your request for an exception to income withholding: 5. Information Required by the Uniform Child Custody Jurisdiction and Enforcement Act. 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 County, State Parent(s)/Caretaker Current Address or Contact Address of Parent/Caretaker Which Children □ Additional page attached; see section labeled “UCCJEA Information 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 kind of proceeding) RESPONSE □ and COUNTERCLAIM – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER American LegalNet, Inc. ORS 21.111 (WITH UCCJEA INFORMATION) - PAGE 2 OF 3 Separation-2C: Response2CVer03.doc (2/08) www.FormsWorkflow.com I do not know any person other than my spouse/partner 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) 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. STATE OF OREGON County of ) ) ss. ) I, , being duly sworn, say that I am the respondent in this matter, and that the statements in this Response are true and correct to the best of my knowledge. Signature Address or Contact Address Print Name City, State, Zip SIGNED AND SWORN to before me this by Telephone or Contact Telephone day of , 20 , . Notary Public for My Commission Expires: /Court Clerk I certify that this is a true copy: Respondent, Signature RESPONSE □ and COUNTERCLAIM – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER American LegalNet, Inc. ORS 21.111 (WITH UCCJEA INFORMATION) - PAGE 3 OF 3 Separation-2C: Response2CVer03.doc (2/08) www.FormsWorkflow.com