Superior Court of Washington County of [ ] In re the Marriage of: [ ] In re the Domestic Partnership of: No. Order of Child Support Petitioner, and Respondent. [ ] Temporary (TMORS) [ ] Final Order (ORS) Clerk’s Action Required I. Judgment Summary [] [] Does not apply because no attorney’s fees or back child support has been ordered. The judgment summary: A. B. C. Judgment creditor Judgment debtor Principal judgment amount (back child support) $ from (date) ______________ to (date) ______________ Interest to date of judgment $ Attorney fees $ Costs $ Other recovery amount $ Principal judgment shall bear interest at __________ % per annum Attorney fees, costs and other recovery amounts shall bear interest at __________ % per annum Attorney for judgment creditor Attorney for judgment debtor Other: D. E. F. G. H. I. J. K. L. Order of Child Support (TMORS, ORS) - Page 1 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com II. Basis 2.1 Type of Proceeding This order is entered under a petition for dissolution of marriage or domestic partnership, legal separation, or declaration concerning validity: [] decree of dissolution, legal separation or a declaration concerning validity. [] order for modification of child support. [] hearing for temporary child support. [] order of adjustment. [] order for modification of a custody decree or parenting plan. [] other: 2.2 Child Support Worksheet The child support worksheet which has been approved by the court is attached to this order and is incorporated by reference or has been initialed and filed separately and is incorporated by reference. 2.3 Other III. Findings and Order It Is Ordered: 3.1 Children for Whom Support is Required Name (first/last) 3.2 Age Person Paying Support (Obligor) Name (first/last): Birth date: Service Address: (You may list an address that is not your residential address where you agree to accept legal documents.) The Obligor Parent Must Immediately File With the Court and the Washington State Child Support Registry, and Update as Necessary, the Confidential Information Form Required by RCW 26.23.050. The Obligor Parent Shall Update the Information Required by Paragraph 3.2 Order of Child Support (TMORS, ORS) - Page 2 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com Promptly After any Change in the Information. The Duty to Update the Information Continues as long as any Support Debt Remains due Under This Order. [] [] 3.3 Monthly Net Income: $ _______________ The income of the obligor is imputed at $ _______________ because: [] the obligor’s income is unknown. [] the obligor is voluntarily unemployed. [] the obligor is voluntarily underemployed. [] other: Person Receiving Support [Obligee] Name (first/last): Birth date: Service Address: (You may list an address that is not your residential address where you agree to accept legal documents.) The Obligee Must Immediately File With the Court and the Washington State Child Support Registry and Update as Necessary the Confidential Information Form Required by RCW 26.23.050. The Obligee Shall Update the Information Required by Paragraph 3.3 Promptly After any Change in the Information. The Duty to Update the Information Continues as Long as any Monthly Support Remains Due or any Unpaid Support Debt Remains Due Under This Order. [] [] Monthly Net Income: $ _______________ The income of the obligee is imputed at $ _______________ because: [] [] [] [] the obligee’s income is unknown. the obligee is voluntarily unemployed. the obligee is voluntarily underemployed. other: The obligor may be able to seek reimbursement for day care or special child rearing expenses not actually incurred. RCW 26.19.080. Order of Child Support (TMORS, ORS) - Page 3 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com 3.4 Service of Process Service of Process on the Obligor at the Address Required by Paragraph 3.2 or any Updated Address, or on the Obligee at the Address Required by Paragraph 3.3 or any Updated Address, may Be Allowed or Accepted as Adequate in any Proceeding to Establish, Enforce or Modify a Child Support Order Between the Parties by Delivery of Written Notice to the Obligor or Obligee at the Last Address Provided. 3.5 Transfer Payment The obligor parent shall pay the following amounts per month for the following children: Amount Name $ $ $ $ Total Monthly Transfer Amount $ [] The parents’ combined monthly net income exceeds $7,000 and the court sets child support in excess of the advisory amount because: [] If one of the children changes age brackets, the child support shall be as follows: [] This is a downward modification that has caused an overpayment of $ ______________. This amount shall be repaid or credited as follows: [] This is an upward modification that has caused an underpayment of $______________. This amount shall be paid as follows: [] Other: The Obligor Parent’s Privileges to Obtain or Maintain a License, Certificate, Registration, Permit, Approval, or Other Similar Document Issued by a Licensing Entity Evidencing Admission to or Granting Authority to Engage in a Profession, Occupation, Business, Industry, Recreational Pursuit, or the Operation of a Motor Vehicle may Be Denied or may Be Suspended if the Obligor Parent is not in Compliance With This Support Order as Order of Child Support (TMORS, ORS) - Page 4 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com Provided in Chapter 74.20A Revised Code of Washington. 3.6 Standard Calculation $ 3.7 per month. (See Worksheet line 15.) Reasons for Deviation From Standard Calculation [ ] The child support amount ordered in paragraph 3.5 does not deviate from the standard calculation. [ ] The child support amount ordered in paragraph 3.5 deviates from the standard calculation for the following reasons: [ ] Income of a new spouse or new domestic partner of the parent requesting a deviation for other reasons; [ ] Income of other adults in the household of the parent requesting a deviation for other reasons; [ ] Child support actually paid or received for other children from other relationships; [ ] Gifts; [ ] Prizes; [ ] Possession of wealth; [ ] Extraordinary income of a child; [ ] Tax planning which results in greater benefit to the children; [ ] A nonrecurring source of income; [ ] Extraordinary debt not voluntarily incurred; [ ] A significant disparity in the living costs of the parents due to conditions beyond their control; [ ] Special needs of disabled children; [ ] Special medical, educational, or psychological needs of the children; [ ] The child spends a significant amount of time with the parent who is obligated to make a support transfer payment. The deviation does not result in insufficient funds in the receiving parent’s household to meet the basic needs of the child. The child does not receive public assistance; [ ] Children from other relationships; [ ] Costs incurred or anticipated to be incurred by the parents in compliance with courtordered reunification efforts or under a voluntary placement agreement with an agency supervising the child; [ ] The obligor has established that it is unjust or inappropriate to apply the presumptive minimum payment of $25.00 per child. [ ] Other: The factual basis for these reasons is as follows: [ ] Other: 3.8 Reasons why Request for Deviation Was Denied Order of Child Support (TMORS, ORS) - Page 5 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com [] [] [] 3.9 Does not apply. A deviation was ordered. A deviation was not requested. The deviation sought by the [ ] obligor [ ] obligee was denied because: [] no good reason exists to justify deviation. [] other: Starting Date and Day to Be Paid Starting Date: Day(s) of the month support is due: 3.10 Incremental Payments [] [] 3.11 ________________________ ________________________ Does not apply. This is a modification of child support. Pursuant to RCW 26.09.170 (9)(a) and (c), the obligation has been modified by more than 30 percent and the change would cause significant hardship. The increase in the child support obligation set forth in Paragraph 3.5 shall be implemented in two equal increments, one at the time of this order and the second on (date) _______________ six months from the entry of this order. How Support Payments Shall Be Made Select Enforcement and Collection, Payment Services Only, or Direct Payment: [] Enforcement and collection: The Division of Child Support (DCS) provides support enforcement services for this case because: [ ] this is a public assistance case, [ ] this is a case in which a parent has requested services from DCS, [ ] a parent has signed the application for services from DCS on the last page of this support order. (Check all that apply.) Support payments shall be made to: Washington State Support Registry P. O. Box 45868 Olympia, WA 98504 Phone: 1-800-922-4306 or 1-800-442-5437 [] Payment services only: The Division of Child Support will process and keep a record of all payments but will not take any collection action. Support payments shall be made to: Washington State Support Registry P. O. Box 45868 Olympia, WA 98504 Phone: 1-800-922-4306 or 1-800-442-5437 Order of Child Support (TMORS, ORS) - Page 6 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com [] Direct Payment: Support payments shall be made directly to: Name Mailing Address ________________________________________ A party required to make payments to the Washington State Support Registry will not receive credit for a payment made to any other party or entity. The obligor parent shall keep the registry informed whether he or she has access to health insurance coverage at reasonable cost and, if so, to provide the health insurance policy information. 3.12 Wage Withholding Action Withholding action may be taken against wages, earnings, assets, or benefits, and liens enforced against real and personal property under the child support statutes of this or any other state, without further notice to the obligor parent at any time after entry of this order unless an alternative provision is made below: [If the court orders immediate wage withholding in a case where Division of Child Support does not provide support enforcement services, a mandatory wage assignment under Chapter 26.18 RCW must be entered and support payments must be made to the Support Registry.] [] Wage withholding, by notice of payroll deduction or other income withholding action under Chapter 26.18 RCW or Chapter 74.20A RCW, without further notice to the obligor, is delayed until a payment is past due, because: [] the parties have reached a written agreement that the court approves that provides for an alternate arrangement. [] the Division of Child Support provides support enforcement services for this case [see 3.11] and there is good cause [as stated below under "Good Cause"] not to require immediate income withholding which is in the best interests of the child and, in modification cases, previously ordered child support has been timely paid. [] the Division of Child Support does not provide support enforcement services for this case [see 3.11] and there is good cause [as stated below under "Good Cause"] not to require immediate income withholding. Good Cause: 3.13 Termination of Support Order of Child Support (TMORS, ORS) - Page 7 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com Support shall be paid: [] [] [] [] [] [] 3.14 Post Secondary Educational Support [] [] [] [] 3.15 provided that this is a temporary order, until a subsequent child support order is entered by this court. until the child(ren) reach(es) the age of 18 or as long as the child(ren) remain(s) enrolled in high school, whichever occurs last, except as otherwise provided below in Paragraph 3.14. until the child(ren) reach(es) the age of 18, except as otherwise provided below in Paragraph 3.14. after the age of 18 for (name) ______________________________ who is a dependent adult child, until the child is capable of self-support and the necessity for support ceases. until the obligation for post secondary support set forth in Paragraph 3.14 begins for the child(ren). Other: The right to petition for post secondary support is reserved, provided that the right is exercised before support terminates as set forth in paragraph 3.13. The parents shall pay for the post secondary educational support of the child(ren). Post secondary support provisions will be decided by agreement or by the court. No post secondary educational support shall be required. Other: Payment for Expenses not Included in the Transfer Payment [] [] Does not apply because all payments, except medical, are included in the transfer payment. The petitioner shall pay __________% and the respondent __________ % (each parent’s proportional share of income from the Child Support Schedule Worksheet, line 6) of the following expenses incurred on behalf of the children listed in Paragraph 3.1: [] day care. [] educational expenses. [] long distance transportation expenses. [] other: Payments shall be made to [ ] the provider of the service [ ] the parent receiving the transfer payment. [] The obligor shall pay the following amounts each month the expense is incurred on behalf of the children listed in Paragraph 3.1: [] [] day care: $ _______________ payable to the [ ] day care provider [ ] other parent; educational expenses: $ _______________ payable to the [ ] educational provider [ ] other parent; Order of Child Support (TMORS, ORS) - Page 8 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com [] [] 3.16 long distance transportation: $ _______________ payable to the [ ] transportation provider [ ] other parent. other: Periodic Adjustment [] [] [] 3.17 Does not apply. Child support shall be adjusted periodically as follows: Other: Income Tax Exemptions [] [] [] [] 3.18 Does not apply. Tax exemptions for the children shall be allocated as follows: The parents shall sign the federal income tax dependency exemption waiver. Other: Medical Insurance for the Children Listed in Paragraph 3.1 Unless one or more of the alternatives below are checked, each parent shall maintain or provide health insurance coverage if: (a) Coverage that can be extended to cover the child(ren) is or becomes available to each parent through employment or is union-related; and (b) The cost of such coverage for the petitioner does not exceed $______________ (25 percent of petitioner’s basic child support obligation on Worksheet line 7), and the cost of such coverage for the respondent does not exceed $_____________ (25 percent of respondent’s basic child support obligation on Worksheet Line 7). [ ] Alternative 1: The parent below shall maintain or provide health insurance coverage if coverage that can be extended to cover the child(ren) is or becomes available to that parent through employment or is union-related and the cost of such coverage does not exceed $____________ (25 percent of that parent's basic child support obligation on Worksheet line 7). [ ] petitioner [ ] respondent [ ] Alternative 2: The parent below shall maintain or provide health insurance coverage if coverage that can be extended to cover the child(ren) is or becomes available to that parent through employment or is union-related even if such coverage exceeds $_____________ (25 percent of that parent's basic child support obligation on Worksheet line 7). [ ] petitioner [ ] respondent [ ] Alternative 3: The parent below is not obligated to provide health insurance coverage because the other parent provides insurance coverage: Order of Child Support (TMORS, ORS) - Page 9 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com [ ] petitioner [ ] respondent The parent(s) shall maintain health insurance coverage, if available for the children listed in paragraph 3.1, until further order of the court or until health insurance is no longer available through the parents’ employer or union and no conversion privileges exist to continue coverage following termination of employment. A parent who is required under this order to provide health insurance coverage is liable for any covered health care costs for which that parent receives direct payment from an insurer. A parent who is required under this order to provide health insurance coverage shall provide proof that such coverage is available or not available within 20 days of the entry of this order to the physical custodian or the Washington State Support Registry if the parent has been notified or ordered to make payments to the Washington State Support Registry. If proof that health insurance coverage is available or not available is not provided within 20 days, the parent seeking enforcement or the Department of Social and Health Services may seek direct enforcement of the coverage through the other parent’s employer or union without further notice to the other parent as provided under Chapter 26.18 RCW. 3.19 Extraordinary Health Care Expenses Unless specifically ordered otherwise, the person receiving support is responsible for ordinary health care expenses of the children. However, both parents have an obligation to pay their share of extraordinary health care expenses. Extraordinary health care expenses mean those monthly medical expenses that exceed 5% of the basic support obligation from the Child Support Schedule Worksheet, Line 5. The petitioner shall pay __________% of extraordinary health care expenses (unless stated otherwise, the petitioner’s proportional share of income from the Worksheet, line 6) and the respondent shall pay ___________% of extraordinary health care expenses (unless stated otherwise, the respondent’s proportional share of income from the Worksheet, line 6). 3.20 Back Child Support [] [] [] [] 3.21 No back child support is owed at this time. Back child support that may be owed is not affected by this order. The obligee parent is awarded a judgment against the obligor parent in the amount of $ _______________ for back child support for the period from (date) _______________ to (date) ______________________. Other: Back Interest [] No back interest is owed at this time. Order of Child Support (TMORS, ORS) - Page 10 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com [] [] [] 3.22 Back interest that may be owed is not affected by this order. The obligee parent is awarded a judgment against the obligor parent in the amount of $ _______________for back interest for the period from (date) ___________________ to (date) __________________________. Other: Other Dated: Judge/Commissioner Presented by: Approved for entry: Notice of presentation waived: Signature of Party or Lawyer/WSBA No. Signature of Party or Lawyer/WSBA No. Print Name Print Name [] I apply for full support enforcement services from the DSHS’ Division of Child Support (DCS). (Note: If you never received TANF, tribal TANF, or AFDC, an annual $25 fee applies if over $500 is disbursed on a case, unless the fee is waived by DCS.) Signature of Party [] Approval required in Public Assistance cases. The DSHS’ Division of Child Support received notice required by RCW 26.23.130. This order has been reviewed and approved as to: [] [] [] [] Current Child Support Back Child Support Medical Support Other: ____________________________________________ Deputy Prosecuting Attorney/WSBA No. Order of Child Support (TMORS, ORS) - Page 11 of 11 PF DR 01.0500 Mandatory (6/2008) - RCW 26.09.175; 26.26.132 American LegalNet, Inc. www.FormsWorkflow.com