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 SPOUSAL SUPPORT AN D 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 , 20 , in case number , in the 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 years of birth), (c) The parties have agreed to joint custody of the following child/ren: (Names and years of birth), as described in the attached parenting plan, labeled "Exhibit 1." 2. Father Mother shall have parenting time with the child/ren in accordance with 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. /// STIPULATION TO MODIFY CUSTODY PARENTING TIME CHILD SUPPORT, SPOUSAL SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 1 of 10 American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer13.doc (9/10) www.FormsWorkFlow.com 3. Child Support, including Cash Medical 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 year(s) of birth) 4. Cash Child Support. Complete either (a) or (b) below: (a) Cash child support must be paid by Petitioner to Respondent (or) Respondent to Petitioner beginning on the first or of the month following the date of the judgment and continuing on the same day of each month thereafter. The total payment per month is $ for children. The cash child support: Is the amount presumed to be appropriate under the support guidelines. Is different from the presumed appropriate amount of $ reasons) (b) 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: 5. Medical Support. Complete section (a) or (b) below. Also complete section (c) or (d) below. Complete (a) or (b): 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 is/are ordered to obtain and/or maintain this coverage throughout the period of the support obligation for the benefit of the parties' child/ren. Health care coverage is not ordered in this judgment because it has already been ordered in another case as described in section 2(b) above. (b) 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 must provide appropriate private health care coverage for the child/ren when such coverage becomes available to them at a reasonable cost through any source. STIPULATION TO MODIFY CUSTODY PARENTING TIME CHILD SUPPORT, SPOUSAL SUPPORT, AND SUPPLEMENTAL JUDGMENT [ORS 107.135; 107.174] - Page 2 of 10 American LegalNet, Inc. Modification-4C: ModStipJudgWithSupport4CVer13.doc (9/10) www.FormsWorkFlow.com because (list . (a)  The custodial parent shall enroll or maintain the child/ren in public health care coverage. Complete (c) or (d): (c) Cash Medical Support 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 ordered to maintain private health insurance, in addition to cash child support Petitioner Respondent must pay $ for cash medical support to Petitioner Respondent, or Because neither parent has appropriate private health care coverage available for the parties' child/ren: Petitioner must pay cash medical support in the monthly amount of $ to Respondent and/or Respondent must pay cash medical support in the monthly amount of $ to Petitioner. (d) Cash Medical Support Not Ordered. Cash medical support is not ordered for the following reasons: The parent paying cash child support is also providing health care coverage. Section (e) below requires the parties to share the cost of the child/ren's uninsured medical expenses. Petitioner's Respondent's gross monthly income is at or below the Oregon minimum wage for full-time employment. Other reason: (e) Responsibility for Uninsured Health Expenses. After the custodial parent pays the first $250 per year per child, Petitioner must pay % and Respondent must pay % of the reasonably incurred uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is in addition to instead of any cash medical support ordered above in paragraph 2 as part of the child support award. 6. Length of Child Support. Unless the child becomes self-supporting, emancipated, or married: The support ordered in paragraphs 4 and 5 above for each child shall continue until the child reaches eighteen (18) years of age. The support ordered in paragraphs 4 and 5 above for each child shall continue until the child reaches age 21 if the child qualifies for support as a child attending school as defined by Oregon law. NOTICE ABOUT PERIODIC