MEDIATION SUPPORT AGREEMENT (DATED ........................................... ) This Court222s Case No. ................................................ Commonwealth of Virginia DCSE ID No. ................................................................. ............................................................................................................. [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court .............................................................................................................................................................................................................................................................................................. STREET ADDRESS OF COURT Petitioner: v.Respondent:[ ] Identifying information not provided for good cause shown[ ] Identifying information not provided for good cause shownResidential Address: Residential Address: Residential Telephone No.: Residential Telephone No.: Mailing Address if Different: Mailing Address if Different: Social Security No. (last 4 digits only): Social Security No. (last 4 digits only): Driver222s Lic. No. & State: Driver222s Lic. No. & State: Date of Birth: Date of Birth: Employer: Employer: Address: Address: Telephone No.: Telephone No.: PRESENT : [ ] Petitioner [ ] Attorney/ Guardian Ad Litem for Petitioner [ ] DCSE Representative [ ] Attorney for DCSE [ ] Respondent [ ] Attorney/ Guardian Ad Litem for Respondent [ ] Guardian Ad Litem for child(r en) [ ] Mediator [ ] The parties agree that [ ] this (these) dependents [ ] a parent of the Respondent in necessitous circumstances: NAME SOC. SEC. # (last 4 digits only) SEX DATE OF BIRTH RELATIONSHIP TO RESPONDENT is (are) entitled to support from the Respondent, and that the Respondent is chargeable with support as alleged in the petition. Therefore, the parties agree that the Respondent to pay: [ ] $ .......................................... per month CURRENT CHILD SUPPORT effective ........................................... for all children listed above; OR [ ] $ .......................................... per month CURRENT CHILD SUPPORT effective ........................................... divided among the above-listed children as follows: $ ............................................... for ................................................ $ ............................................... for ............................................... $ ............................................... for ................................................ $ ............................................... for ............................................... [ ] $ .......................................... per month CURRENT SPOUSAL SUPPORT effective ......................................... [ ] $ .......................................... per month COMBINED CHILD-SPOUSAL (UNITARY) SUPPORT effective ...................................... [ ] $. .......................................... per month SUPPORT FOR A PARENT effective ........................................... [ ] $ .......................................... per month PAYMENT TOWARDS ARREARAGES OF $ .......................................... TOTAL $ ................................... per month payable, first payment due on the 1st day of ......................................... , and each subsequent payment is due on the 1st day of each month thereafter. Payments may be made in intervals of ...................................... , per .............................. , beginning PAYMENT AMOUNT INTERVAL on ............................................. DATE All support paid shall be credited to current support first and the remainder shall be credited to arrearages. Child support shall terminate on a child222s eighteenth birthday; however, support shall continue for any child who is over the age of eighteen and (i) a full-time high school student, (ii) not self-supporting and (iii) living in the home of the parent receiving child support, until the child reaches the age of nineteen or graduates from high school, whichever occurs first; and if any arrearages for child support, including interest or fees, exist at the time the youngest child emancipates, payments shall continue in the total amount due until all arrearages are paid. If the above current child support is not divided per child, the ordered amount cannot be changed except by a court. [ ] Support for , a child whom the court has determined (i) is severely and permanently mentally Name of Child or physically disabled, and such disability existed prior to the child reaching the age of 18, or the age of 19 if the child was a full-time high school student, not self-supporting and living in the home of the parent seeking or receiving child support; (ii) is unable to live independently and support himself and (iii) residing in the home of the parent seeking support. FORM DC-631 (MASTER, PAGE ONE OF THREE) 07/15 ........................................................................................................................................ ........................................................................................................................................................................................................................................................................................................................................................................................................................ American LegalNet, Inc. www.FormsWorkFlow.com MEDIATION SUPPORT AGREEMENT Case No. .................................................................... ARREARAGES: [ ] No arrearages exist as of .................................... [ ] $ ................................. child support arrearage owed by Respondent. [ ] $ ................................. spousal support arrearage owed by Respondent. [ ] $ ................................. unitary (child/spousal) support arrearage owed by Respondent. [ ] $ ................................. total SUPPORT arrears owed by Respondent [ ] with interest included [ ] without interest included [ ] arrears include an assessment from the effective date of this order to the first payment due date. [ ] This total includes TANF debt or other public funds paid prior to the effective date of this order of $ ..................................... for ....................... months. These arrearages are calculated as of the date of this Agreement including support owed for the current month. This amount does not include payments made after //, and respondent shall be credited for any payments made thereafter. Interest shall continue to accrue on unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest. PAYMENT: Payment shall be made payable to: [ ] Petitioner at the address shown in the beginning of the Agreement. The parties shall give the court at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer. [ ] Treasurer of Virginia and sent to Virginia Department of Social Services, Division of Child Support Enforcement, P.O. Box 570, Richmond, Virginia 23218-0570 unless otherwise instructed by that agency or this Court and shall contain the following: 1.Check or money order made payable to the Treasurer of Virginia.2.Print on the check or money order:Your name and social security numberPetitioner222s name as shown on the first page of this agreementThe DCSE ID No. shown on the first page of this agreement. If no such number is shown, use this Court222s name and casenumber as shown on the front page of this agreement until that number is sent to you; then start using the DCSE ID No.The parties shall give to the Virginia Department of Social Services and the court, at least 30 days written notice, in advance, of any proposed change of residential and, if different, mai