IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF __________________ In the Matter of ‘ the Marriage of: ) ) ) ) ) ) ) ) ) ) ) ________________________________, Petitioner, and ________________________________, Respondent and Case No. ____________________ SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT RE: ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT, and ‘ ORDER RE: JURISDICTION ) ‘ ________________________________, ) Child who is at least 18 and under 21 years of age, unmarried and unemancipated. (ORS 107.108) ) ) ) 1. This matter came before the Court: a. ‘ On the motion and affidavit to modify judgment of ‘ Petitioner ‘ Respondent, ‘ and because the party moved against did not file a written response to the motion; b. ‘ On the motion and affidavit to modify judgment of ‘ Petitioner ‘ Respondent, the default of ‘ Petitioner ‘ Respondent having been found. c. ‘ On the stipulations of the parties, as shown by the signatures below d. ‘ At a hearing held ______________________, at which the following persons were present: (Date) ‘ Petitioner ‘ Respondent ‘ Petitioner’s attorney ‘ Respondent’s attorney 2. Findings. The Court considered the: ‘ Affidavit ‘ Stipulations ‘ Evidence presented and found that: a. Child Custody Jurisdiction. (Check appropriate boxes) ‘ Oregon has jurisdiction under the Uniform Child Custody Jurisdiction and Enforcement Act to hear the ‘ custody ‘ parenting time issue(s) because: i. If Oregon is the issuing state: ‘ The child/ren has/have resided in Oregon continuously for the six month period before commencement of this proceeding; or ‘ Other basis for jurisdiction: Page 1 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com ii. If Oregon is not the issuing state (indicate state of issuance: ): ‘ Neither the child/ren nor the parents presently reside in the issuing state. ‘ Other basis for jurisdiction: ‘ Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because: 3. ‘ Custody. A substantial change in circumstance has occurred since the last custody order and it would be in the child/ren’s best interests to change the custody terms. 4. ‘ Parenting Time. It would be in the child/ren’s best interests to change the parenting time terms. 5. ‘ Child Support. A change in custody, parenting time, or other circumstance, has occurred requiring a change in the current support obligation. 6. 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. IT IS THEREFORE ORDERED that: The Judgment is modified as follows: a. Custody: i. ‘ Petitioner ‘ Respondent is awarded sole custody of the child/ren (list names): (Names and dates of birth) ii. ‘ The parties have agreed to joint custody of the following child/ren (list names): (Names and dates of birth) /// /// /// /// Page 2 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 7. Parenting Time: a. ‘ Petitioner ‘ Respondent should have parenting time with the child/ren ‘ as set forth in the attached Parenting Plan, labeled Exhibit ____, or ‘ Other: b. ‘ Petitioner ‘ Respondent should not be granted parenting time because this would endanger the health and safety of the child/ren. Supporting facts are as follows: c. ‘ Parenting time shall be supervised by: ‘ Any cost of the supervision shall be paid by ‘ Petitioner ‘ Respondent ‘ Other: d. ‘ Petitioner and Respondent should each provide contact addresses and contact telephone numbers to the other and notify each other of any emergency circumstances or substantial changes in the child/ren’s health. e. ‘ 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. 8. Child Support: a. ‘ 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. b. ‘ 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. c. ‘ This order shall modify and replace the following existing order: (list court/agency and case no.) because the court finds that 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 this order was entered. /// /// Page 3 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 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.(UTCR 8.060(5)) ii. ‘ The support award does not deviate from the amount presumed correct under the guidelines set out in the Oregon Administrative Rules. 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): ‘ Recurring medical expenses of __________________________________________________ _____________________________________________________________________________, ‘ Other ______________________________________________________________________. 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. f. 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 request, collection, accounting disbursement, and enforcement services of this obligation shall be through the State of Oregon’s Department of Justice. (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 Page 4 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 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. 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. 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. g. Life Insurance Coverage for Child/ren. ‘ 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 $_________________________. 9. 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 Page 5 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 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. 10. Court Costs and Fees. a. Deferred Costs and Fees. Any court costs and service fees (if service was completed by the Sheriff) that were deferred (required to be paid at a later date) by the court shall be paid by: ‘ Petitioner ‘ Respondent ‘ Both parties equally ‘ Other: _______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ b. Costs and Fees Paid by the Parties ‘ Each party shall be responsible for paying his or her own court costs and service fees for this case. ‘ To be paid by both parties equally ‘ Petitioner ‘ Respondent shall reimburse the other spouse for his or her court costs and service fees for this case. Other: Judgment shall be entered according to the cost and fee allocation listed above. 11. 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. 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 ‘ Page 6 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com 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 $ be paid by (date): to 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 Postjudgment Interest G Petitioner G Respondent (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) G Petitioner G Respondent 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. Page 7 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com Type of Judgment Accrued Arrears (if any, on judgments to be paid on a periodic basis) Amount of Judgment 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) Attorneys Fees (if any) WHO PAYS G Petitioner G Respondent $ WHO RECEIVES G Petitioner G Respondent WHO PAYS G Petitioner G Respondent $ WHO RECEIVES G Petitioner G Respondent 12. Preservation of General Judgment Terms. Any terms in the original Judgment not amended by this Supplemental Judgment shall remain in effect. DATED this ________ day of ________________________________, 20______. ______________________________________ Circuit Court Judge _______________________________________ Print Name /// /// /// /// /// /// /// Page 8 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com ‘ Both parties have agreed (stipulated) to the terms of this judgment: (sign only your name) Petitioner, Signature Respondent, Signature ‘ 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 , 20 by person(s)). , (date) (name of _______________________________________ 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 Certificate of Mailing. I certify that I mailed a copy of this judgment and attachments thereto by U.S. Mail with postage paid to the other party at the following address:________________________________________ ___________________________________________ on the following date:_______________________. ___________________________________________ ‘ Petitioner ‘ Respondent, Signature _________________________________ Print Name I certify that this is a true copy: ______________________________________ ‘ Petitioner ‘ Respondent, Signature Page 9 of 9, SUPPLEMENTAL JUDGMENT MODIFYING JUDGMENT Modification-4A: Judgment4AVer09.wpd (09/06) American LegalNet, Inc. www.FormsWorkflow.com