Superior Court of Washington County of No. In re the Parenting and Support of: Child(ren), Petitioner, and Judgment and Order Establishing [ ] Residential Schedule/ Parenting Plan [ ] Child Support (Out-of-State Acknowledgment of Paternity) (JDORS) Respondent. Clerk’s action required ¶ 3.4, 3.5, 3.6 3.8 [ ] Law Enforcement Notification, ¶ 3.8 I. Judgment/Order Summaries 1.1 Restraining Order Summary: [ ] Does not apply. [ ] Restraining Order Summary is set forth below: Name of person(s) restrained: protected: . Name of person(s) . See Paragraph 3.8. Violation of a Restraining Order in paragraph 3.8 below with actual knowledge of its terms is a criminal offense under Chapter 26.50 RCW and will subject the violator to arrest. RCW 26.26.590. 1.2 Money Judgment Summary: [] A. B. C. D. Does not apply. [ ] Judgment Summary is set forth below: Judgment creditor Judgment debtor Total judgment amount Principal judgment amount (back support) From _____ to _____ E. Interest to date of judgment F. Attorney fees G. Costs $ $ $ $ $ Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 1 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com H. I. J. K. L. 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 II. Basis This matter has come before this court, the court considered the case record and has previously entered its findings of fact and conclusions of law. III. Order It is Ordered: 3.1 Jurisdiction Over the Child The court has jurisdiction over the child(ren) as set forth in the findings of fact and conclusions of law. 3.2 Order of Child Support [] [] 3.3 Residential Placement [] [] [] [] [] 3.4 Does not apply. _________________________ [Name] shall pay child support as set forth in the order of child(ren) support which was signed by the court on ________________________ [Date]. The primary residence of the child shall be with ______________________ [Name], who is designated custodian solely for the purpose of other state and federal statutes. The residential plan/parenting plan signed by the court on __________________ [Date] is adopted and incorporated by reference. ______________________________ [Name] shall be designated the custodian of the child, and the child shall reside with _______________________ [Name] at all times. Determination of residential time of ________________________________ [Name] with the child is denied. Other: Judgment for Back Child Support (Note – do not repeat this judgment in the order of child support WPF PS 01.0500.) [] [] [] Does not apply. _________________________________ [Name] is awarded a judgment against ________________________ [Name] in the amount of $__________________, for back child support for the period from _______________ [Date] to _______________ [Date]. The unpaid support due to _________________________________ [Name] by ______________________________ [Name] is waived and will not be collected by Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 2 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com [] ____________________________ [Name]. This does not waive any support owing to the state as a result of payment of public assistance. All support due under temporary court orders has been paid. Unpaid support due under a court or administrative order is preserved for collection and is not merged in or extinguished by this order. Other: [] Collection Limitation Against Wages: [] [] The back child support provision above shall be paid at a rate of at least $__________ per month beginning __________________ [Date]. So long as the payments for current support, back support and the judgment are timely, collection against the judgment debtor’s wages, excluding bonuses and other lump sum payments, shall be limited to $_______________ per month (for current support, back support and judgment). This limitation terminates if a single payment is past due. This provision does not limit or bar the state of Washington from using other collection remedies available to it by law, including, but not limited to, certification for collection to the Internal Revenue Service. Payment shall be made to: [] 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 judgment debtor at any time after entry of an order by the court, except as limited by the Collection Limitation Against Wages paragraph above. [] Wage withholding, by notice of payroll deduction or other income withholding action under Chapter 26.18 RCW or Chapter 74.20 RCW, without further notice to the judgment debtor, is delayed until a payment is past due, because: [] [] [] there is good cause not to require immediate income withholding. the parties have reached a written agreement which the court approves that provides for an alternative arrangement. (See below): Judgment and Back Support Payments Shall Be Made to: [] [] 3.5 ____________________________________ ____________________________________ Washington State Support Registry P.O. Box 45868 Olympia, Washington 98504 Phone: 1-800-922-4306 1-800-442-5437 Judgment (Note – do not repeat this judgment in the order of child support WPF PS 01.0500.) Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 3 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com [] [] Does not apply. _______________________________________ [Name] is awarded a judgment against _______________________________ [Name] in the amount of $_________, as follows: [ ] $__________ for genetic testing costs. [ ] $__________ for guardian ad litem fees. [ ] $__________ for attorney fees. [ ] $__________ costs. [ ] $__________ for other fees and expenses. [ ] $__________ other: [ ] ___________________ [Name] shall have judgment against ____________________ [Name] for _________________________________________ in the amount of $______________. 3.6 County Costs [] [] [] 3.7 Does not apply. The Superior Court of __________________________ shall have judgment against _____________________________ [Name] for costs of this action specified as follows: Other: Guardian ad Litem [] [] [] 3.8 Does not apply. Any guardian ad litem appointed by the court is discharged. Other: Continuing Restraining Order [] [] Does not apply. A continuing restraining order is entered as follows: [] [] [] ______________________________ [Name] is restrained and enjoined from disturbing the peace of the other party. _______________________________ [Name] is restrained and enjoined from going onto the grounds of or entering the home, work place or school of the other party, or the day care or school of the following named children: _______________________________________________________________. _____________________________ [Name] is restrained and enjoined from knowingly coming within or knowingly remaining within _________________ [Distance] of the home, work place or school of the other party, or the day care or school of these children: ____________________________________________. Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 4 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com Other: ________________________________________________________. [] [] _____________________________ [Name] is restrained and enjoined from molesting, assaulting, harassing or stalking _____________________ [Name]. (The following firearm restrictions apply if this box is checked: Effective immediately and continuing as long as this continuing restraining order is in effect, the restrained person may not possess a firearm or ammunition. 18 U.S.C. § 922(g)(8). A violation of this federal firearms law carries a maximum possible penalty of 10 years in prison and a $250,000 fine. An exception exists for law enforcement officers and military personnel when carrying department/government-issue firearms. 18 U.S.C. § 925(a)(1).) Other: Violation of a restraining order in paragraph 3.8 with actual knowledge of its terms is a criminal offense under Chapter 26.50 RCW and will subject the violator to arrest. RCW 26.26.130. [] Service [] [] Clerk’s Action. The clerk of the court shall forward a copy of this order, on or before the next judicial day, to______________________________________ [name of the appropriate law enforcement agency] which shall enter this order into any computerbased criminal intelligence system available in this state used by law enforcement agencies to list outstanding warrants. (A law enforcement information sheet must be completed by the party or the party’s attorney and provided with this order before this order will be entered into the law enforcement computer system.) The restrained party or attorney appeared in court or signed this order; service of this order is not required. The restrained party or attorney did not appear in court; service of this order is required. Expiration [Month/Day/Year]. This This restraining order expires on: restraining order supersedes all previous temporary restraining orders in this cause number. [] Any temporary restraining order previously entered in this cause number is terminated. Clerk’s Action. The clerk of the court shall forward a copy of this order, on or before the next judicial day, to: ______________________________ law enforcement agency where Petitioner resides which shall enter this order into any computer-based criminal intelligence system available in this state used by law enforcement agencies to list outstanding warrants. Full Faith and Credit Pursuant to 18 U.S.C. § 2265, a court in any of the 50 states, the District of Columbia, Puerto Rico, any United States territory, and any tribal land within the United States shall accord full faith and credit to the order. 3.9 Protection Order [] Does not apply. Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 5 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com [] 3.10 The parties shall comply with the Order for Protection signed by the court on this date, _____________________________ in this cause number. The Order for Protection signed by the court is approved and incorporated as part of this decree. 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 or Type Name Date _____________________________________ Print or Type Name Date Approval required in Public Assistance cases. _____________________________________ Signature of Party or Lawyer/WSBA No. 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: _____________________________________ Print or Type Name Date Public Assistance DPA Signature/WSBA No. Print or Type Name Date Judgment/Ord Parenting Plan/Child Support (JDORS) - Page 6 of 6 WPF PS 15A.0500 (6/2006) - RCW 26.26.350, 26.27.201, 42 U.S.C. 666(a)(11) American LegalNet, Inc. www.USCourtForms.com