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. ______________________ STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT; AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] Based upon the request and stipulation of the parties, as shown by the notarized signatures below, and it appearing to the Court that a judgment of annulment, dissolution of marriage, separation, or establishing paternity, custody and parenting time was granted in this case on , in the , 20 , in case number County Circuit Court, that the parties jointly request a modification of the custody, parenting time and/or child support provisions of this judgment; Now, therefore, IT IS HEREBY ORDERED that: 1. Custody: a. ‘ The judgment with respect to custody remains in effect and unchanged. b. ‘ Petitioner ‘ Respondent is awarded sole custody of the child/ren (Names and dates of birth) c. ‘ The parties have agreed to joint custody of the following child/ren: (Names and dates of birth) as described in the attached parenting plan, labeled “Exhibit 1.” Page 1 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com 2. ‘ Father ‘ Mother shall have parenting time with the child/ren in accordance with 9 the attached parenting plan, labeled “Exhibit 1”, or as follows: ‘ 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. 3. Child Support: a. ‘ Child support as previously ordered remains in effect and unchanged. b. ‘ The Judgment is modified to terminate ‘ Petitioner’s ‘ Respondent’s support obligation effective for the child/ren: (name(s) and date(s) of birth) due to the change in custody. c. ‘ 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 support for each child shall continue until the child reaches eighteen (18) years of age, or is otherwise emancipated, unless the child is a student attending school as defined by Oregon law, in which case support shall continue until the child reaches 21 years of age. Until further order, the total payment per month shall be $___________________ for _____________ children. d. ‘ 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): e. Child Support Calculation. i. ‘ The child support worksheet on which the support amount was calculated is labeled “Exhibit ____" and attached to and incorporated in this judgment, or ii. ‘ The support award does not deviate from the amount presumed correct under the guidelines set out in the Oregon Administrative Rules, or iii. ‘ The support amount presumed correct under the guidelines set out in Oregon Administrative Rules is $ _______________. The support award deviates from this amount because this Court finds that application of the formula would be unjust or inappropriate in this case because of (check one or more that apply): Page 2 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com ‘ Recurring medical expenses of _______________________________________________________________, ‘ Other ___________________________________________________________________________________. f. Child/ren Who Are At Least 18 and Under 21 Years of Age. ________________________________ (child/ren’s name) is at least 18 and under 21 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. 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 two years from the date the order took effect or at any time upon a substantial change of circumstances. g. 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. i. ‘ 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: (a) ‘ The parents, and the State, if support rights are assigned, have agreed in writing to an alternative arrangement, or (b) ‘ 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. ii. ‘ 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). By petitioner’s or respondent’s request, collection, accounting disbursement, and enforcement services of this obligation shall be through the State of Oregon’s Department of Justice. Page 3 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com NOTICE OF INCOME WITHHOLDING This 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. (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. 4. Life Insurance Coverage for Child/ren. ‘ The judgment with respect to life insurance coverage for the parties’ children remains in effect and unchanged, or ‘ Petitioner ‘ Respondent shall obtain and maintain life insurance for the benefit of the child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $_________________________. 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. Page 4 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com 5. Medical Insurance Coverage for Child/ren. ‘ Petitioner ‘ Respondent shall name the child/ren as beneficiaries of any health, accident, dental, orthodontic and optical insurance plan, throughout the period of the support obligation, whenever such insurance is available through this 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 this parent fails to maintain the insurance under these circumstances, this parent shall be responsible for any of those expenses incurred after the date of this judgment. If this parent maintains the required insurance but the insurance does not provide complete coverage, this parent shall pay _______% of the uninsured costs, excluding those anticipated costs listed in Section 3 of this judgment. If this parent provides insurance that is available through his or her employment, group or union membership and this employment or membership then terminates, 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, this parent shall provide insurance in the future when it becomes available to him/her. ‘ Whenever ‘ Petitioner ‘ Respondent does not have health, accident, dental, orthodontic, or optical insurance available through employment, group, or union membership, this parent shall pay ______% of the reasonably incurred uninsured medical, dental, orthodontic, optical and prescription medicine costs incurred for the child/ren throughout that period, excluding those anticipated costs listed in Section 3 of this judgment. 6. Unchanged Terms of Judgment Remain in Effect. Any terms in the Judgment not changed by this Supplemental Judgment shall remain in full force and effect. 7. Money Award. Child Support Obligation ‘ included ‘ not included. Additional information required by ORS 18.042 PETITIONER RESPONDENT Full Name Address or Contact Address Attorney’s Name, Telephone Number and Address (if applicable) Date of Birth Driver’s License Number and State of Issuance The following information is to be provided by any party entitled to receive a money award (a “judgment creditor”) as listed in this Judgment. Page 5 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com 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 G Petitioner G Respondent WHO RECEIVES G Petitioner G Respondent Spousal Support Award WHO PAYS G Petitioner G Respondent WHO RECEIVES G Petitioner G Respondent Property Division (if applicable) $ ‘ Other: the judgment. ‘ per month or ‘ Other: , starting on the ‘ first day or of the month following the date of ‘ per month or ‘ Other: , starting on the ‘ first 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 1. $ 2. A lump sum payment of $ paid by (date): to be WHO PAYS G Petitioner G Respondent WHO RECEIVES G Petitioner G Respondent 1. $ per month, starting on the ‘ first day or ‘ Other: of the month following the date of the is paid in judgment until the total amount of $ full; or 2. A lump sum payment of $ (date). to be paid by: Prejudgment Interest G Petitioner G Respondent WHO PAYS (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) WHO RECEIVES $ . G Petitioner G Respondent Page 6 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com Type of Judgment Amount of Judgment Postjudgment Interest G Petitioner G Respondent (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) G Petitioner G Respondent Accrued Arrears (if any, on judgments to be paid on a periodic basis) WHO PAYS WHO RECEIVES percent ( %) per annum simple interest on . the total judgment amount(s) of $ Interest begins accruing on the date the judgment is entered until fully paid. WHO PAYS G Petitioner G Respondent WHO RECEIVES G Petitioner G Respondent 1. $ per month, starting on the ‘ first day or ‘ Other: of the month following the date of the is paid in judgment until the total amount of $ full; or 2. A lump sum payment of $ (date). to be paid by: Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees) WHO PAYS G Petitioner G Respondent . $ Attorneys Fees (if any) $ . WHO RECEIVES G Petitioner G Respondent WHO PAYS G Petitioner G Respondent WHO RECEIVES G Petitioner G Respondent DATED this ________ day of ________________________________, 20______. ______________________________________ Circuit Court Judge _______________________________________ Print Name Page 7 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com Both parties have agreed to the terms of this Judgment. Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on by , 20 , (date) (name of person(s)). ____________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ Respondent, Signature State of County of ) ) This instrument was acknowledged before me on by , 20 , (date) (name of person(s)). ____________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ Page 8 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com ‘ 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 by , 20 , (date) (name of person(s)). ____________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ 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 City, State, Zip Telephone or Contact Telephone I certify that this is a true copy: ______________________________________ ‘ Petitioner ‘ Respondent, Signature Page 9 of 9, STIPULATION TO MODIFY ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer11.wpd (11/06) www.FormsWorkflow.com