COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... SUPERIOR COURT OF WASHINGTON COUNTY OF THE PEOPLE OF THE STATE OF NEW YORK TO In re the Parenting and Support of: NO. Child(ren) GREETINGS: ORDER OF CHILD SUPPORT [ Temporary (TMORS) WE COMMAND YOU, thatPetitioner and excuses]being laid aside, you and each of you attend before all business and [ ] Final Court (ORS) Order , the Honorable at the located at County of Clerk’s Action Required noon, and at any recessed in room , on the day of , 20 , at o'clock in the Respondent. or adjourned date, to testify and give evidence as a witness in this action on the part of the I. JUDGMENT SUMMARY [] Does not apply because no this subpoena is back child as a contempt of court and Your failure to comply withattorney’s fees or punishable support has been ordered. will make you liable to [ The judgment summary: the ]party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. A. Judgment creditor B. JudgmentHonorable Witness, debtor , one of the Justices of the C. Principal judgment amount (back child support) $ Court in County, day of , 20 from ______________ [Date] to ______________ [Date] D. Interest to date of judgment $ E. Attorney’s fees $ (Attorney must sign above and type name below) F. Costs $ G. Other recovery amount $ H. Principal judgment shall bear interest at __________ % per annum I. Attorney’s fees, costs and other recovery amounts shall bear interest at __________ % per annum Attorney(s) for J. Attorney for judgment creditor K. Attorney for judgment debtor L. Other: Office and P.O. Address Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 1 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : II. BASIS Plaintiff(s) 2.1 TYPE OF PROCEEDING. -against- Calendar No. : JUDICIAL SUBPOENA : This order is entered pursuant to: : [] a decree of dissolution, legal separation or a declaration of invalidity. : [] an order determining parentage. [] an order for modification of child support. Defendant(s) : [ . . . . a .hearing. for .temporary . . . . .support.. . . . . . . . . . . ] ......... . . . . . . . . . . . . . . . . child . . . . . . [] an order of adjustment. [] an order for modification of a custody decree or parenting plan. [] other: THE PEOPLE OF THE STATE OF NEW YORK 2.2 TO 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. GREETINGS: 2.3 OTHER: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of III. FINDINGS AND at , 20 , ORDER o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the IT IS ORDERED that: 3.1 CHILDREN FOR WHOM SUPPORT IS REQUIRED. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Age Name result of your failure to comply. (first/last) Witness, Honorable Court in County, 3.2 , one of the Justices of the day of PERSON PAYING SUPPORT (OBLIGOR). , 20 (Attorney must sign above and type name below) Name (first/last): Birth date: Service Address: [You may list an address that is not your residential address where you agree to Attorney(s) for accept legal documents.] THE OBLIGOR PARENT MUST IMMEDIATELY FILE WITH THE COURT AND THE Office and P.O. Address WASHINGTON STATE CHILD SUPPORT REGISTRY, AND UPDATE AS NECESSARY, THE CONFIDENTIAL INFORMATION FORM REQUIRED BY RCW 26.23.050. Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 2 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : THE OBLIGOR PARENT SHALL UPDATE THE INFORMATION REQUIRED BY JUDICIAL SUBPOENA Plaintiff(s) PARAGRAPH 3.2 PROMPTLY AFTER ANY CHANGE IN THE INFORMATION. THE -against: 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 obligor is imputed at $_______________ because: Defendant(s) : [] the obligor’s income is unknown. ...................................................... [] the obligor is voluntarily unemployed. [] the obligor is voluntarily underemployed. [] other: THE PEOPLE OF THE STATE OF NEW YORK [] [] 3.3 TO 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 GREETINGS: legal documents.] accept WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County ofTHE OBLIGEE MUST IMMEDIATELY FILE WITH THE COURT AND THE in room WASHINGTON STATE CHILD SUPPORT REGISTRY, AND UPDATE AS NECESSARY, recessed , on the day of , 20 , at o'clock in the noon, and at any or adjourned date, to testify and give evidence as a witness in this action BYthe part26.23.050. on RCW of the THE CONFIDENTIAL INFORMATION FORM REQUIRED THE OBLIGEE SHALL UPDATE THE INFORMATION REQUIRED BY PARAGRAPH 3.3 PROMPTLY AFTER ANY CHANGE IN THE INFORMATION. THE DUTY TO UPDATE Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to THE INFORMATION CONTINUES AS LONG AS ANY MONTHLY SUPPORT REMAINS the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a DUE OR ANY UNPAID SUPPORT DEBT REMAINS DUE UNDER THIS ORDER. result of your failure to comply. [] Monthly Net Income: $_______________. [] The income Witness, Honorable of the obligee is imputed at $_______________one of the Justices of the , because: [ ] County, the obligee’s income is unknown. Court in day of , 20 [] the obligee is voluntarily unemployed. [] the obligee is voluntarily underemployed. [] other: (Attorney must sign above and type name below) The obligor may be able to seek reimbursement for day care or special child rearing expenses not actually incurred. RCW 26.19.080. Attorney(s) for 3.4 SERVICE OF PROCESS. SERVICE OF PROCESS ON THE OBLIGOR AT THE ADDRESS REQUIRED BY Office and P.O. OBLIGEE AT THE PARAGRAPH 3.2 OR ANY UPDATED ADDRESS, OR ON THE Address ADDRESS REQUIRED BY PARAGRAPH 3.3 OR ANY UPDATED ADDRESS, MAY BE ALLOWED OR ACCEPTED AS ADEQUATE IN ANY PROCEEDING TO ESTABLISH, Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 3 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : ENFORCE OR MODIFY A CHILD SUPPORT ORDER BETWEEN THE PARTIES BY JUDICIAL SUBPOENA Plaintiff(s) DELIVERY OF WRITTEN NOTICE TO THE OBLIGOR OR OBLIGEE AT THE LAST -against: ADDRESS PROVIDED. 3.5 : TRANSFER PAYMENT. : The obligor parent shall pay the following amounts per month for the following children: Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name . . . . . . . . . . . . . . .... Amount $ $ $ $ THE PEOPLE OF THE STATE OF NEW YORK TO TOTAL MONTHLY TRANSFER AMOUNT [] GREETINGS: $ The parents’ combined monthly net income exceeds $7,000 and the court sets child support in excess of the advisory amount because: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court If one of the children changes age brackets, the child support shall be as follows: located at County of[ ] in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the [] This is a downward modification that has caused an overpayment of $ ________. This amount shall be repaid or credited as follows: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a [] This comply. result of your failure tois an upward modification that has caused an underpayment of $_______. This amount shall be paid as follows: Witness, Honorable Court in [ ] County, Other: , one of the Justices of the day of , 20 (Attorney must sign above and type name below) 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 Attorney(s) for 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 PROVIDED IN Office and CHAPTER 74.20A REVISED CODE OF WASHINGTON. P.O. Address 3.6 STANDARD CALCULATION. Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 4 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : : $_______________ per month. (See Worksheet line 15.) Plaintiff(s) 3.7 Index No. Calendar No. JUDICIAL SUBPOENA -against: 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: Defendant(s) [] Income of a new spouse of the parent requesting a deviation for other reasons; : . . . . . . . . . . . .[ .] . . . Income .of. other .adults .in.the .household . . .the .parent requesting a deviation for other . . . . . . . . . . . . . . . . . . . . . . . . . . of . . reasons; [] Child support actually paid or received for other children from other relationships; [] Gifts; THE PEOPLE OF THE STATE OF NEW YORK [] Prizes; [] Possession of wealth; TO [] 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; GREETINGS: ] [ A significant disparity in the living costs of the parents due to conditions beyond their control; WE [ ] COMMAND needs of disabled children; excuses being laid aside, you and each of you attend before Special YOU, that all business and , the Honorable[ ] Court Special medical, educational, orat the psychological needs of the children; located at County of [] The child spends a significant amount of time with the parent who is obligated to make in room , on the transferof , deviation does noto'clockin insufficient funds inat any recessed , at noon, and the a support day payment. The 20 result in the or adjourned date, to testify and give evidence as towitness inbasic action of the child. The child does not a meet the this needs on the part of the receiving parent’s household receive public assistance; [] Children from other relationships; [] Costs incurred or anticipated to be incurred by the parents in compliance with courtYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ordered reunification efforts or under a voluntary placement agreement with an agency the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a supervising the child; result of your failure to comply. [] The obligor has established that it is unjust or inappropriate to apply the presumptive minimum payment of $25.00 per child. Witness, Honorable , one of the Justices of the [] Other: Court in County, day of , 20 The factual basis for these reasons is as follows: (Attorney must sign above and type name below) Attorney(s) for [ ] Other: 3.8 REASONS WHY REQUEST FOR DEVIATION WAS DENIED. Office and P.O. Address [] [] Does not apply. A deviation was ordered. A deviation was not requested. Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 5 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) The deviation sought by the [ ] obligor [ ] obligee was denied because: -against: [] no good reason exists to justify deviation. [] other: : 3.9 STARTING DATE AND DAY TO BE PAID. : Starting Date: _______________ Day(s) of the month support is due: Defendant(s) _______________ : ...................................................... 3.10 INCREMENTAL PAYMENTS. [] [] Does not apply. THE PEOPLE OF THE STATE OF NEW child support. Pursuant to RCW 26.09.170 (9)(a) and (c), the [] This is a modification of YORK obligation has been modified by more than 30 percent and the change would cause TO 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. GREETINGS: SUPPORT PAYMENTS SHALL BE MADE. 3.11 HOW Select Enforcement and that all business and excuses being laid Direct Payment: WE COMMAND YOU,Collection, Payment Processing Only, oraside, you and each of you attend before , the Honorable at the Court Enforcement and collection: The Division of Child Support (DCS) provides support located at County of[ ] enforcement services for this case, because: at ] This is a public assistance case,and this is arecessed in room , on the day of 20 , [ o'clock in the noon, [ ] at any case in which a parent has requested services from DCS, [ the parent has signed the ] a part of the or adjourned date, to testify and give evidence as a witness in this action on 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 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalfP. O. subpoena was issued for a maximum penalty of $50 and all damages sustained as a this Box 45868 Olympia, WA 98504 result of your failure to comply. Phone: 1-800-922-4306 or 1-800-442-5437 Witness, Honorable , one of the Justices of the Court in [ ] County, day The Division , 20 Payment services only:of 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 [] (Attorney must sign above and type name below) Attorney(s) for Direct Payment: Support payments shall be made directly to: Office and P.O. Address Name Mailing Address ________________________________________ Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 6 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) A party required to make payments to the Washington State Child Support Registry will not -against: 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. : Defendant(s) Withholding action may be taken against wages, earnings, assets, or benefits, and liens enforced : . . . . . . . . against real.and. personal . . . . . . . .under .the .child. support statutes of this or any other state, . . . . . . . . . . . . . . . . . . property . . . . . . . . . . . . . . . without further notice to the obligor parent at any time after entry of this order unless an alternative provision is made below: THE PEOPLE OF THE STATE OF NEW YORK [If the court orders immediate wage withholding in a case where DCS does not provide support enforcement services, a mandatory wage assignment under Chapter 26.18 RCW must be entered TO and support payments must be made to the Support Registry.] [] GREETINGS: 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 written agreement which the court approves you WE COMMAND YOU, that all businessaand excuses being laid aside, you and each ofthat attend before provides for an alternate arrangement. , the Honorable at the Court located Child Support provides support enforcement services for this case at County of [] the Division of in room , on the[see 3.11] and there is good cause,[as stated below under "Goodnoon, and at any recessed day of , 20 at o'clock in the Cause"] not to or adjourned date, to testify and give evidence as a witness in thiswhich is inthe part of the action on the best interests of the child require immediate income withholding and, in modification cases, previously ordered child support has been timely paid. Your failure to comply with thisChild Support does not provide supportof court and will makefor liable to [] the Division of subpoena is punishable as a contempt enforcement services you the party on whose behalfthis case [see 3.11] and there isagood cause [as stated belowand all "Good Cause"] this subpoena was issued for maximum penalty of $50 under damages sustained as a result of your failure to comply. require immediate income withholding. not to Good Cause: Witness, Honorable Court in County, 3.13 __________________________________________________ of the , one of the Justices __________________________________________________ day of , 20 __________________________________________________ __________________________________________________ TERMINATION OF SUPPORT. (Attorney must sign above and type name below) Support shall be paid: provided that this is a temporary order, until a Attorney(s) child support order is entered subsequent for by this court. [] until the child(ren) reach(es) the age of 18, except as otherwise provided below in Paragraph 3.14. [] until the child(ren) reach(es) the age of 18 or as long as the child(ren) remain(s) enrolled Office and P.O. Address in high school, whichever occurs last, except as otherwise provided below in Paragraph 3.14. [] after the age of 18 for ______________________________ [Name] who is a dependent Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 7 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: [] American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : [] [] 3.14 Index No. Calendar No. : adult child, until the child is capable of self-support and the necessity for support ceases. JUDICIAL SUBPOENA Plaintiff(s) until the obligation for post secondary support set forth in Paragraph 3.14 begins for the -against: child(ren). other: : POST SECONDARY EDUCATIONAL SUPPORT. : Defendant(s) : [] No post secondary educational support shall be required. ...................................................... [] 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 THE PEOPLE OF THE STATE OF NEW YORK provisions will be decided by agreement or by the court. [] Other: TO 3.15 PAYMENT FOR EXPENSES NOT INCLUDED IN THE TRANSFER PAYMENT. GREETINGS: [] Does not YOU, that all business and except being laid aside, you and each of you WE COMMANDapply because all payments, excusesmedical, are included in the transfer attend before payment. , the Honorable at the Court The mother shall pay __________% and the father __________% (each parent’s located at County of[ ] proportional share of income from the Child Support Schedule Worksheet, line 6) of the in room , on the day of , 20 , at o'clock in the noon, and at any recessed following expenses incurred on behalf of the children listed in Paragraph 3.1: or adjourned date, to testify and give evidence as a witness in this action on the part of the [] day care. [] educational expenses. [ ] to comply with this subpoena is expenses. as a contempt of court and will make you liable to long distance transportation punishable Your failure [ the party on whose]behalfother:subpoena was issued for a maximum penalty of $50 and all damages sustained as a this result of your failure to comply. Payments shall be made to [ ] the provider of the service [ ] the parent receiving the Witness, Honorable , one of the Justices of the transfer payment. Court in County, day of , 20 [] 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(Attorney must sign above and type name below) to the [ ] day care provider [ ] other parent; [] educational expenses: $_______________ payable to the [ ] educational provider [ ] other parent; [] Attorney(s) for long distance transportation: $______________ payable to the [ ] transportation provider [ ] other parent. [] other: Office and P.O. Address 3.16 PERIODIC ADJUSTMENT. Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 8 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. [] [] : Does not apply. JUDICIAL Plaintiff(s) Child support shall be adjusted periodically as follows: -against: [] Other: SUBPOENA : : 3.17 INCOME TAX EXEMPTIONS. Defendant(s) : . . . . . . . . [ . . . . . .Does not apply. . . . . . . . . . . . . . . . . . . . . . . . . . . . .] ............ [] Tax exemptions for the children shall be allocated as follows: [] The parents shall sign the federal income tax dependency exemption waiver. THE PEOPLE OF THE STATE OF NEW YORK [] Other: TO 3.18 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: GREETINGS: (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 WEThe cost of such coverageall business anddoes not exceedlaid aside, you and each of you attend before (b) COMMAND YOU, that for the mother excuses being $____ (25 percent of mother’s basic , the Honorable support obligation on Worksheet line 7), and the cost ofCourt coverage for the father does at the child such located father’s basic child support obligation. See Worksheet line 7). County ofnot exceed $____ (25 percent ofat in room , on the day of , 20 , at o'clock in the noon, and at any recessed [ ] date, to testify The parent below as a maintain this action on the part of the or adjournedAlternative 1: and give evidence shallwitness inor 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. See Worksheet line 7). Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to [ ] behalf the party on whose mother this subpoena was issued for a maximum penalty of $50 and all damages sustained as a [ ] father result of your failure to comply. [ ] Alternative 2: The parent below shall maintain or provide health insurance coverage if Witness, that can be one of the that parent coverage Honorable extended to cover the child(ren) is or becomes,available toJustices of the Court in through employment or is union-related even if 20 coverage exceeds $______ (25 percent of County, day of , such that parent's basic child support obligation. See Worksheet line 7.). [ ] mother [ ] father (Attorney must sign above and type name below) [ ] Alternative 3: The parent below is not obligated to provide health insurance coverage: Attorney(s) for [ ] mother [ ] father This parent is not obligated to provide health insurance coverage because: Office and P.O. Address [ ] the other parent provides insurance coverage [ ] other: Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 9 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA -against: 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 Defendant(s) : 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 OF NEW YORK THE PEOPLE OF THE STATE or the Washington State Support Registry if the parent has been notified or ordered to make payments to the Washington State Support Registry. TO If proof that health insurance coverage is available or not available is not provided within 20 days, the obligee or the Department of Social and Health Services may seek direct enforcement of the coverage through the obligor’s employer or union without further notice to the obligor as provided under Chapter 26.18 RCW. GREETINGS: 3.19 EXTRAORDINARY HEALTH CARE EXPENSES. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County ofThe OBLIGOR shall pay __________% of extraordinary health care expenses (the obligor’s proportional share of income from the Child Support Schedule Worksheet, line 6), if monthly in room , on the day of , 20 , at o'clock in the noon, and at any recessed medical expenses exceed $_______________ (5% of the basic support obligation from or adjourned date, to testify and give evidence as a witness in this action on the part of the Worksheet line 5). 3.20 BACK CHILD SUPPORT. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to [] No back this support was issued for a maximum penalty of $50 and all damages sustained as a the party on whose behalf childsubpoenais owed at this time. [ ] failure to child support that may be owed is not affected by this order. Back comply. result of your [] The obligee parent is awarded a judgment against the obligor parent in the amount of $_______________ for back child support for the period from _______________ [Date] Witness, Honorable , one of the Justices of the to _______________ [Date]. Court in [ ] County, day of , 20 Other: (Attorney must sign above and type name below) 3.21 BACK INTEREST. [] [] [] [] No back interest is owed at this time. Back interest that may be owed is not affectedAttorney(s) for by this order. The obligee parent is awarded a judgment against the obligor parent in the amount of $_______________ back interest for the period from _______________ [Date] to _______________ [Date]. Other: Office and P.O. Address Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 10 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : 3.22 : Plaintiff(s) OTHER. -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : Dated: ...................................................... JUDGE/COMMISSIONER Presented by: THE PEOPLE OF THE STATE OF NEW YORK Approved for entry: Notice of presentation waived: TO Signature Signature Print or Type GREETINGS: Name Print or Type Name [] I apply for full support enforcement services excuses being Division you and each of WE COMMAND YOU, that all business andfrom the DSHSlaid aside,of Child Support. you attend before , the Honorable at the Court located at County of Signature of Party in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the [] Approval required in Public Assistance cases. Approved for entry, notice of presentation waived. Deputy Prosecuting Attorney/WSBA No. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Print or Type Name Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: ORDER OF CHILD SUPPORT (TMORS, ORS) - Page 11 of 11 WPF PS 15.0700 (6/2004) - RCW 26.09.105, RCW 26.26.375, RCW Facsimile No.: 26.19 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com