COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 14. Spousal Support, Life Insurance and Medical Coverage. : Plaintiff(s) Index No. Calendar No. JUDICIAL SUBPOENA -against: Spousal Support. Support should be paid by ‘ Husband to Wife ‘ Wife to Husband: : ‘ In the amount of $ per month for the following period of time: , or : ‘ In the amount of $ by (date), or ‘ In an amount to be determined before trial or entry of judgment. Defendant(s) : ...................................................... List reason(s) support should be paid: . THE PEOPLE OF THE STATE OF NEW YORK TO The support shall be called (check one or more): ‘ transitional ‘ compensatory ‘ spousal maintenance based on consideration of the following factors (list): . GREETINGS: Payments. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Payments , the Honorable should be made on the first day of eachthe at month beginning the month following the date the Court judgment isof located at County signed by a judge. All in room payments of spousal support of , on the day should be made: (checkat or (b)): , 20 , (a) o'clock in the noon, and at any recessed Support Accounting Unit, P.O. part of the (a) ‘ To the Department of Justice, Childas a witness in this action on theBox 14506, Salem, Oregon, or adjourned date, to testify and give evidence 97309. Petitioner requests that collection, accounting, disbursement, and enforcement services be provided through the Department of Justice. (Required if child support is paid through the state.) (b) ‘ Directly into __________________________________’s checking or savings account. A receipt of deposit should be kept by to comply with this subpoena is punishable as a contempt of court and should provide the to Your failure the paying spouse as proof of payment. The spouse receiving support will make you liable paying party on whose behalf this subpoena was issued foraccount name, and account number. damages sustained as a the spouse with current deposit slips and/or bank name, a maximum penalty of $50 and all result of your failure to comply. Withholding. ‘ If child support is also ordered in this case and if enforcement services one provided through the State of Witness, Honorable , are of the Justices of the Oregon’s Department of Justice, the spousal support order should be enforceable by income withholding under ORS Court in County, day of , 20 25.378. Life Insurance. (Attorney benefit of ‘ Husband below) ‘ Husband ‘ Wife should buy and maintain life insurance for themust sign above and type name ‘ Wife throughout the period of the spousal support obligation, in the amount of $__________________. Medical Coverage. Attorney(s) for ‘ Husband ‘ Wife should buy and maintain health, accident, dental and optical insurance for the benefit of ‘ Husband ‘ Wife, if insurance is available through his/her employment, group or union. The insurance payments should be additional spousal support, and should be treated as such for tax purposes. If coverage for a former spouse is available through the purchasing spouse’s employment, group or union, Office and P.O. Address and this membership is later terminated, the purchasing spouse should notify the other spouse of this before or immediately upon termination. Page 5a - PETITION FOR DISSOLUTION Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Disso-1B: PetitionSupp1BVer03.wpd (11/03) American LegalNet, Inc. www.USCourtForms.com