Free Form 1 Petition for Custody and Parenting Time - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN In the Matter of: ) ) ________________________________, ) Petitioner, ) ) ) and ) ) ________________________________, ) Respondent. ) ) ) and ) ) ________________________________, ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) )

Case No. ______________________ PETITION FOR CUSTODY AND PARENTING TIME under ORS 109.103 and CHILD SUPPORT

DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111

Petitioner is the mother father and Respondent is the mother father of (names of children): , born on the following date/s: 1. 2. Paternity has been established: by filing with the State Registrar of Vital Statistics a voluntary acknowledgment of paternity, concerning the following child/ren (e.g., birth certificate): (list name/s of child/ren involved) by administrative order docketed with the following court: , as case number , located in county, concerning the following child/ren:

(list name/s of child/ren involved) by judicial order entered in the following court: : , as case number , located in county, concerning the following child/ren:

(list name/s of child/ren involved) by another method: concerning the following child/ren: (list name/s of child/ren involved)
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3. The minor child/ren reside/s in The Petitioner resides in The Respondent resides in 4.

County, State of County, State of County, State of

UCCJEA Information. The child/ren listed above has/have continuously resided in Oregon for the six months preceding the filing of this case. List the places where the minor child/ren of the parties has/have lived in the last five years and the names of the people they lived with at that time. Dates From/To County, State Parent(s)/Caretaker Current Address/ Contact Address of Parent/Caretaker Which Children



Additional page attached; see section labeled "paragraph 4 continued."

I have have not participated in any litigation concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following litigation: Name of Court State Case No. Date Result

I do not know of any other domestic violence, custody, visitation, parenting time or placement proceeding involving the child/ren, or of any other court case which could affect this case, pending in this or any other state except for: (identify court, case number and the kind of proceeding) I do not know any person other than the other parent who has physical custody of the child/ren or who claims to have custody, visitation or parenting time rights except for

(list name and address) 5. Parenting Plan (Custody and Parenting Time). Custody of the child/ren should be awarded as follows: Petitioner should be awarded sole custody of the following child/ren (list names):

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Unmarried Parents-3A: STATE Petition.doc (1/08)

Respondent should be awarded sole custody of the following child/ren (list names): The parties have agreed to joint custody of the following child/ren (list names): Petitioner Respondent should have parenting time with the child/ren as set forth in the attached Parenting Plan, labeled Exhibit , or Other:

Petitioner Respondent should not be granted parenting time because this would endanger the health and safety of the child/ren. State supporting facts:

Parenting time should be supervised by Any cost of the supervision shall be paid by Petitioner Respondent Other: Petitioner and Respondent should each provide contact addresses and contact telephone numbers to the other and notify each other of any emergency circumstances or substantial changes in the child/ren's health. Petitioner should be allowed to move more than 60 miles further distant from the other parent without advance notice because good cause exists. 6. Child Support, including Health Care Coverage and Cash Medical Support. A. Other Pending Child Support Cases. (Check one.) No other agency or court child support proceeding is currently pending (include any child support matter being heard as part of a dissolution, separation, annulment, paternity, support or modification case). There is/are other child support proceeding(s) currently pending in either an agency or court case as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDER attached to this petition. Other Child Support Orders. (Check one.) No other child support orders, from an agency or court, are currently in effect in the State of Oregon or any other state. There is/are other child support orders from an agency or court as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDERS/JUDGMENTS attached to this petition. Currently Effective Child Support Order. (Check any that apply.) The following child support order/s is/are currently in effect: (List state, court/agency, case number, date of order) This order should remain in place, or This order is from an Oregon court or agency, one of the parents or the child/ren receiving support still resides in Oregon and the order should be changed because circumstances have changed since the last order was entered. State facts showing how circumstances have changed:

B.

C.

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Unmarried Parents-3A: STATE Petition.doc (1/08)

The following child support proceeding has been started but is not yet resolved (an order has not yet been issued): (list court/agency, and case number) D. Child Support in this Case. No child support should be ordered in this case because: Child support has already been ordered as described in "C" above and this order should remain in place. Other reason: Child support should be paid by Petitioner to Respondent (or) Respondent to Petitioner beginning on the first day of the month following the date of the judgment and continuing on the first (1st) day of each month thereafter. Under the Support Guidelines set out in Oregon's Administrative Rules, the total payment of child support per month should be: $ for children, as reflected in the attached Worksheets, or determined prior to judgment. If a specific amount is indicated above, that amount: does not deviate from the amount presumed correct under the guidelines. deviates from the amount presumed correct under the guidelines because application of the formula would be unjust or inappropriate in this case because of (check one or more that apply) Recurring medical expenses (describe): Other: includes Cash Medical Support For out-of-pocket medical expenses exceeding $250 per year per child in the amount of $ and/or To reimburse for public health care costs in the amount of $ (Check if applicable Petitioner Respondent and/or Child/ren are eligible for public medical assistance and should not be ordered to pay cash medical support. All payments of child support should be made to the Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). Petitioner requests that collection, accounting, disbursement, and enforcement services be provided by the Department of Justice. In addition, support for a child attending school (between the ages of 18 and 21) as defined by Oregon law shall be distributed by the Department of Justice directly to the child subject to ORS 107.108. (Applies only if support enforcement services are not being provided.) Petitioner requests an exception to the income withholding requirement of ORS 25.378 allowing payment to be made directly to Petitioner's Respondent's checking or savings account. A receipt of deposit should be kept by the parent paying support as proof of payment. The parent receiving support should provide the paying parent with current deposit slips and/or bank name, account name, and account number. Health care coverage. (Check any that apply.)

E.

1.) PRIVATE INSURANCE IS AVAILABLE A.) THROUGH ONE PARENT
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Unmarried Parents-3A: STATE Petition.doc (1/08)

Petitioner or Respondent has/have appropriate private health care coverage available for the parties' child/ren either through an employer, union, or other source, or through a domestic partner, spouse or other family member residing with them (describe type of coverage): I request that Petitioner Respondent be ordered to maintain this coverage throughout the period of the support obligation for the benefit of the parties' child/ren. B.) THROUGH BOTH PARENTS Both Petitioner and Respondent have appropriate private health care coverage available for the parties' child/ren. I select the following health care coverage to be maintained throughout the period of the support obligation: Petitioner's Respondent's Both Petitioner's and Respondent's (describe type/s of coverage): 2.) NO PRIVATE INSURANCE IS AVAILABLE NOW Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties' child/ren A.) Petitioner Respondent Both Petitioner and Respondent should be ordered to apply for and enroll the child/ren in public health care coverage. B.) Petitioner Respondent has already applied to enroll the child/ren in public health care coverage. This coverage should be maintained if the child/ren are accepted for enrollment. C.) The child/ren are currently enrolled in public health care coverage. This coverage should be maintained. D.) Both Petitioner and Respondent should be ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. 3.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES Petitioner should pay % and Respondent should pay % of the uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND OPTICAL HEALTH costs incurred by the child/ren. This obligation is in addition to any cash medical support requested in paragraph 6(D) as part of the child support award. F. (Check one.) Petitioner Respondent shall be entitled to claim the following child/ren as dependent(s) for tax purposes beginning the year this judgment is entered (list names): OR Other (specify): G. The support payments for each child should continue until the child reaches 18 years of age or is otherwise emancipated, or until the child reaches age 21, so long as the child is a student attending school, as defined by Oregon law.

7.

Life Insurance Coverage for Child/ren. Petitioner Respondent should obtain and maintain life insurance for the benefit of the parties' child/ren throughout the period of the support obligation. The coverage should be in the amount of $ 8. Additional Provisions.

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Unmarried Parents-3A: STATE Petition.doc (1/08)

Additional page attached; labeled "Paragraph 8 Continued - Additional Provisions." 9. Information Required by ORS 25.020 and ORS 107.085. Disclosure of the following information would unreasonably put to risk the health, safety, or liberty for the following reasons:

of Petitioner Respondent or a child

Otherwise: (Fill out the information in the table below) Petitioner Full Name Former Legal Name(s) Age Address or Contact Address Telephone Number Social Security Number Drivers License Number Employer Name Employer Address Employer Telephone Additional page labeled "Paragraph 9 continued" attached. 10. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service completed by the Sheriff) that are deferred (required to be paid at a later date) by the court should be paid by: Petitioner Respondent Both parties equally Other: B. Costs and Fees Paid by the Parties Each party should be responsible for paying his or her own court costs and service fees for this case. To be paid by both parties equally Petitioner Respondent should reimburse the other party for his or her court costs and service fees for this case. Other: Judgment should be entered according to the cost and fee allocation listed above. Do not list. Provide by UTCR 2.100 Affidavit Do not list. Provide by UTCR 2.100 Affidavit Respondent

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Unmarried Parents-3A: STATE Petition.doc (1/08)

11.

Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. Certificate of Residency. I certify that one or both of the parties to this case currently live in the county in which this petition is being filed.

12.

WHEREFORE, Petitioner requests a Judgment granting the relief asked for above, and other equitable relief that the Court thinks is just. STATE OF County of ) ) ss. )

I, , being duly sworn, say that I am the Petitioner in this matter and that the foregoing petition is true and correct to the best of my knowledge.

Petitioner, Signature

Print Name

Address or Contact Address

City, State, Zip

Telephone or Contact Telephone

SIGNED AND SWORN to before me this by

day of

, 20

_________________________________________ Notary Public for ____________/Court Clerk My Commission Expires: ____________________

I certify that this is a true copy.

_____________________________________ Petitioner, Signature

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Unmarried Parents-3A: STATE Petition.doc (1/08)