Form 802 Page 1 CHILD SUPPORT ORDER Docket Number County Vermont Family Court Plaintiff IN THE MATTER OF: VS. Defendant OBLIGOR'S EMPLOYER OBLIGOR (Person Who Must Pay Support) Last Name First Name Initial Street Address City Street Address State Zip Code Telephone Number Zip Code OBLIGEE'S EMPLOYER Initial First Name Street Address Name Street Address Zip Code State City State Zip Code Telephone Number Telephone Number Social Security Number State Date of Birth OBLIGEE (Person Who Receives Support) City City Telephone Number Social Security Number Last Name Name Date of Birth CHILDREN WHO ARE SUBJECT TO THIS ORDER: Last Name First Name M. Date of Birth Grade Social Security Number Last Name First Name M. Date of Birth Grade Social Security Number Last Name First Name M. Date of Birth Grade Social Security Number Last Name First Name M. Date of Birth Grade Social Security Number Last Name First Name M. Date of Birth Grade Social Security Number Last Name First Name M. Date of Birth Grade Social Security Number Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com Page 2 DOCKET NO. CHILD SUPPORT ORDER I. TYPE OF HEARING, DEFAULT OR STIPULATION This order is entered upon default (failure to file an answer) after default hearing (when one or more parties fail to appear) after hearing (when parties are present and/or represented by counsel) approval of the parties (stipulation filed) II. PARENTAL RIGHTS AND RESPONSIBILITIES FINDINGS AND BASIS OF ORDER A) Physical responsibility for the child(ren) for the purpose of child support is: primarily with split as follows: Child(ren): with Child(ren): with shared as follows: name of parent name of parent % of time with name of parent % of time with name of parent B) Physical responsibility is based on: a stipulation of the parties dated an Order of the Court dated C) D) is/are in the custody of others. Child(ren) Additional information: III. CURRENT CHILD SUPPORT This is the result of a child support worksheet which is attached and incorporated as Findings in this Order and which includes information on other child support related costs, such as child care, extraordinary medical and/or educational expenses. ORDER A) Beginning Date: the Obligor shall pay child support in the amount of $ per time period: B) Beginning Date: $ Rev. 7/06 SML the Obligor shall pay child support maintenance supplement in the amount of per time period: American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER DOCKET NO. Page 3 IV. ARREARS ON PAST DUE CHILD SUPPORT/REPAYMENT PROVISIONS A) ARREARS OWED TO THE OFFICE OF CHILD SUPPORT: the obligor shall pay the Office of Child Support the sum of Beginning Date: $ per (time period): $ as of (date): $ ; medical expenses towards a judgment in the amount of This judgment consists of past due support civil penalty $ ; ; ; surcharge $ ; Attorney fees $ cash contribution toward medical $ B) ; service fees $ $ ; other $ ARREARS OWED TO THE OBLIGEE: Beginning Date: the obligor shall pay to the obligee $ per (time period): towards a judgment in the amount of as of (date): This judgment consists of past due support ; service fees $ $ $ ; medical expenses ; civil penalty $ ; surcharge $ Attorney fees $ $ cash contribution toward medical $ ; ; ; other $ ARREARS OWED TO ANOTHER PERSON OR AGENCY: Beginning Date: $ the obligor shall pay to the per (time period): $ D) as of (date): towards a judgment in the amount of . ADDITIONAL: V. METHOD OF PAYMENT A) WAGE WITHHOLDING ORDER any employer of the Obligor shall deduct the sum of 1) Beginning Date: $ per (time period): This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT, PO BOX 1310, WILLISTON, VT 05495 (NOTE: This provision of this order is subject to the limits on withholding contained in 15 U.S.C. §1673(b) and §303(b) of the Consumer Protection Act.) 2) At any time the child support obligation is not being paid through wage withholding, the responsible parent shall send the payments to the Office of Child Support or the Obligee. (NOTE: Any direct Payments made by the Obligor to the Obligee will not be reflected in OCS records unless OCS received written notification of the direct payment). Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER B) DIRECT PAYMENT - Based upon: 1) Stipulation of the parties or 2) Evidence presented at hearing 1) Beginning Date: per (time period): Page 4 DOCKET NO. the Obligor shall pay the sum of $ to the Office of Child Support. This amount shall be paid directly to: OFFICE OF CHILD SUPPORT, PO BOX 1310, WILLISTON, VT 05495 the Obligor shall pay the sum of 2) Beginning Date: $ to the Obligee. per (time period): (NOTE: If the court finds, after a hearing on a petition, that any support payment has been late by 7 days or more, the court may issue a wage withholding order, pursuant to 15 V.S.A. section 782.) VI. MEDICAL SUPPORT A. Health Insurance CALCULATION TO DETERMINE REASONABLE COST - FINDINGS 1. Private health insurance is available to: Obligee Obligor Neither Gross monthly income is Obligee $ Obligor 5% gross monthly income is $ $ $ Total monthly health insurance premium is $ $ 2. Private health insurance is deemed reasonable for: obligee obligor because: the cost of health insurance is 5% or less of a parent's gross income as calculated above for obligee obligor. the cost of health insurance is in excess of 5% of a parent's gross income and the court has considered the factors of 15 V.S.A. § 659. Additional findings: 3. Although the cost of health insurance is 5% or less of a parent's gross income, the obligee obligor is not required to provide health insurance for the following reasons: MEDICAL SUPPORT ORDER 1) The obligor obligee is ORDERED to provide and maintain private health insurance for the minor child(ren) because the cost for health insurance is deemed reasonable pursuant to the findings set forth above; OR 2) Private health insurance is currently unavailable to either parent at a reasonable cost. If private health insurance becomes available to either parent at a reasonable cost, that parent shall be responsible for providing and maintaining health insurance for the minor child(ren). Either parent may request a hearing to determine whether the cost of health insurance is reasonable. 3) Beginning Date: amount of $ the Obligor shall pay a cash contribution toward the cost of health coverage in the per (time period): . CURRENT MEDICAL SUPPORT COVERAGE Private health insurance. Policy or Certificate Number Name of Subscriber: Relationship to Child(ren) Plan Name and Address Subscriber's I.D. Number B. Expenses Medical or other health expenses that are unreimbursed by insurance (including but not limited to expenses for eye, dental, mental health, health plan deductible) shall be shared/split as follows: % Obligor % Obligee Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER DOCKET NO. Page 5 C) Additional Orders: 1) If employed, a parent under a medical support order shall notify his/her employer of such obligation, in writing, within 10 days of the date of this order. 2) If self-employed or unemployed, a parent under a medical support order shall notify his/her health care insurer of such obligation in writing within 10 days of the date of this order. 3) A parent is liable for any unreimbursed health care costs of the child(ren) that result from a parent's failure to give notice/obtain insurance as ordered above, which accrues between the date of this order and the date that the order is modified by the Court. 4) If a parent has health insurance through an entity other than his/her employer, that parent shall be responsible for maintaining that insurance and complying with any notice requirements under the policy in effect. Failure to do so will make the parent liable for paying any unreimbursed health care expenses that accrue between the date of this order and the date this order is modified by the Court. 5) If a parent pays a health expense of a child subject to this order and the other parent receives reimbursement from insurance for the expense, the reimbursement shall be sent to the parent who advanced payment, within 7 days of receipt. If the child(ren) also have Medicaid coverage, payment is to be sent to the: Office of Health Access 312 Hurricane Drive, Suite 201, Williston, VT 05495-2806, within 7 days. 6) The parties shall provide each other with copies of bills for health expenses and documentation of insurance determination within 7 days of receipt. The parent who maintains insurance shall also provide the other parent with a health insurance card, claim forms and a list of benefits and restrictions within 10 days of the date of this order. 7) Each party shall notify the: Office of Child Support, Support Registry, 103 South Main Street, Waterbury, VT 05671-1901 within 7 days of a change in address, employment or health insurance carrier. This notification requirement applies until all obligations to support arrearages or orders to provide visitation are satisfied. 8) A PARENT OR ANY OTHER PERSON TO WHOM SUPPORT HAS BEEN GRANTED, OR ANY PERSON CHARGED WITH SUPPORT, MAY FILE A MOTION FOR A MODIFICATION OF A CHILD SUPPORT ORDER UNDER 15 VSA SECTION 660. A MODIFICATION MAY BE GRANTED UPON A REAL, SUBSTANTIAL, AND UNANTICIPATED CHANGE OF CIRCUMSTANCES, INCLUDING LOSS OF EMPLOYMENT OR A CONSIDERABLE REDUCTION OR INCREASE IN SALARY OR WAGES. AN OBLIGOR IS RESPONSIBLE FOR ANY REQUIRED PAYMENTS SET FORTH IN AN ORDER UNLESS THE ORDER IS VACATED OR MODIFIED BY A COURT. THUS, ANY SUBSEQUENT AGREEMENT BETWEEN THE PARTIES THAT DIFFERS FROM THE ORDER IS NOT LEGALLY BINDING, AND THE OBLIGOR IS STILL LEGALLY REQUIRED TO PAY THE AMOUNT ORDERED BY THE COURT. (15 VSA, Section 663 (e)). VII. ADDITIONAL FINDINGS AND ORDER ADDITIONAL FINDINGS A) B) C) A Relief from Abuse Order exists for these parties under Docket No. A party's address is omitted for confidentiality purposes after a court finding of good cause. Other: Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER Page 6 DOCKET NO. VIII. DURATION OF CHILD SUPPORT A) This order shall remain in effect unless and until it is changed or discontinued by further order of the Court or operation of law. B) Unless otherwise specified, an Obligor's support obligation will continue beyond a child's eighteenth birthday if the child is enrolled in, but has not completed high school. C) If wage withholding is ordered and an arrearage exists when the support obligation terminates, the monthly current obligation and any arrearage repayment plan shall not be reduced until the amount is satisfied. The above is stipulated by the parties. Date Signature of Obligee Date Date Signature of Obligor Signature of Obligee's Attorney Date Approved as to Form Signature of Obligor's Attorney OCS Representative Date Magistrate/Presiding Judge Date It is so ORDERED. Assistant Judge Date Assistant Judge Date ACCEPTANCE OF SERVICE I have received a copy of this Order and I waive all other service. Obligor Date Obligee Date NOTICE OF RIGHT TO APPEAL An order signed by the Magistrate or Presiding Judge may be appealed by filing a Notice of Appeal with the Clerk of the Family Court within 30 days of filing of this order. Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER Page 7 DOCKET NO. NOTICE OF A PARENT'S RESPONSIBILITY AND RIGHTS A) THIS IS A COURT ORDER All parties are expected to comply with all terms of this Order. The address provided to the Court shall remain the same for service of future actions and/or orders unless a parent notifies the court of a change. B) A PARTY HAS THE RIGHT TO SEEK MODIFICATION OF THE ORDER BY FILING AN ACTION IN COURT A party has the right to request a modification of the child support order based upon a real, substantial, unanticipated change of circumstances or if the support amount has not been modified by the Court for at least three years from the date of the last order. C) RIGHT TO SEEK ENFORCEMENT OF THE ORDER 1. A party may place liens on real or personal property. 2. A party may request the Court to: a) place assets in escrow. b) suspend any and all licenses owned by the Obligor. This may include, but is not limited to, professional, hunting, fishing, or motor vehicle driver's licenses. c) grant a civil penalty when noncompliance of the support is willful. d) order wage withholding if the support amount is at least 7 days delinquent. e) find the Obligor in Contempt if there is willful noncompliance with this order. f) impose surcharges on past due child support. D) IN ADDITION TO THE REMEDIES LISTED ABOVE: A party has the right to request assistance from the Vermont Office of Child Support in the effort to enforce this Order. If the Office of Child Support is or becomes involved in this case, based either on a current or future request for their services, or otherwise, the Office is not limited to but may take the following steps when appropriate: 1. Use any lawful collection remedies to collect any outstanding balance from the Obligor, regardless of any repayment plan on any unpaid debts. 2. Certify all qualifying child support debts to the Vermont Tax Department and/or the Federal Treasury Offset Program for the purpose of intercepting tax returns and/or other payments (i.e., vendor payments, passport denial, etc.) 3. Report an Obligor's account balance to consumer credit reporting agencies and/or request a copy of the report. 4. Administratively issue a wage withholding order for current support and/or arrearages in excess of l/12 of the annual support obligation. 5. Freeze bank accounts and take the proceeds to satisfy past due support. Rev. 7/06 SML American LegalNet, Inc. www.FormsWorkflow.com