Free Form 5 Certificate of Mailing to SED - Oregon

Form 5 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN
IN THE MATTER OF THE MARRIAGE OF SEPARATION OF CUSTODY OF ) ) ) ) ) ) ) ) ) ) )

Case No. _______________________ PETITIONER'S RESPONDENT'S CERTIFICATE OF MAILING TO THE DIVISION OF CHILD SUPPORT

___________________________________, Petitioner, and ___________________________________, Respondent.

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I certify that on __________________, 20______, I mailed a true copy of the Ex Parte Motion, Affidavit for Order for Order to Show Cause regarding Supplemental Judgment in the above case to the local branch office of the Department of Justice, Division of Child Support at: Division of Child Support Albany Office 118 SE 2nd Avenue Suite Albany, OR 97321. 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.
DATED this _____ day of _______________________, 20______.

_____________________________________ Petitioner Respondent, Signature _____________________________________ Print Name _____________________________________ Address or Contact Address _____________________________________ City, State, Zip Code _____________________________________ Telephone or Contact Telephone
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Linn County Form Disso-1B: Form 5 Ce rtificate of Mailing to Child Support.wpd (3/05)