IN THE JUVENILE COURT OF MEMPHIS AND SHELBY COUNTY, TENNESSEE _________________________________________ Petitioner Docket Number ____________________________ V. _________________________________________ Defendant CONSENT ORDER This cause came on to be heard upon a sworn petition to establish parentage and provide support for And it being evident to the Court by the signatures of the parties that they do place themselves before this Honorable Court and acknowledge its jurisdiction and admit the following: 1. That they have been fully advised of their legal rights and that a hearing before the Court is hereby expressly waived. 2. That the _____________ is the natural ______________ and the ____________ is the natural _____________ of said child(ren), that the ________________ is awarded custody of said child(ren) and that ______________ is able to pay by income assignment $_________, fee included, toward the support and education of said child(ren) and agrees to pay said amount to the Central Child Support Receipting Unit. 3. That they are aware that on this agreement is based the Order of this Court, and that failure to comply herewith, without just cause, places them in contempt of Court and subjects them to such action as the Court deems proper within its jurisdiction. Having considered the admissions and agreement of the parties, it is the judgment of the Court that ________________________________________ is the natural father of said child(ren). IT IS THEREFORE ORDERED, ADJUDGED, AND DECREED 1. That said child(ren) shall be a legitimate child(ren) of the natural father for the purposes of inheritance, support and all other lawful purposes and that custody of said child(ren) be awarded to __________________________________________________. 2. That the _______________ pay by income assignment $_________, fee included, to the Central Child Support Receipting Unit toward the support of said child(ren), the first payment to be made on or about the ______ day of _______________, 20 _____. Unless specifically ordered by the Court, such support shall not be reduced or prorated. 3. That the _______________ shall provide medical insurance for the child(ren), or in the alternative, that he be responsible for the child(ren)'s medical expenses. 4. That the _______________ shall pay the costs for which execution may issue. CONSENTED TO: _________________________________________ Petitioner _________________________________________ Defendant This ______ day of ________________, 20 ______ _________________________________________ Juvenile Court Judge 6/15/03 JC-38 American LegalNet, Inc. www.USCourtForms.com