Free Form 03EN003E - Oklahoma

IN THE DISTRICT COURT OF STATE OF OKLAHOMA Petitioner/plaintiff and Respondent/defendant ) ) ) ) )

COUNTY

Case no: CSED FGN: (Child Support Enforcement Division case number)

Summary of Support Order
Mail to: CSED, Central Case Registry, PO Box 528805, Oklahoma City, OK 73152-8805 This form must be completed and presented to the judge before the judge signs your order. The Child Support Enforcement Central Case Registry needs this information to send child support payments. This form will NOT be put on file in the Courthouse. [43 O.S. § 120] 1. The judge made the following order: Protective Order? Temporary or Yes No Final on (date). Active

2. What kind of case was just heard by the judge? Juvenile; Modification of earlier order; Other kind of case, explain: 3. The judge ordered the father or mother of the child(ren) to pay $ or

Divorce; Paternity; Enforcement of earlier order; or .

(name), per month to (name), the father, mother, other caretaker or guardian. The judge said the money is to be paid on the day of each month (date). (date).

4. The first payment was ordered to be paid on

5. Please fill in the boxes below about each child that the judge ordered support to be paid for in this court order. If there are more than eight children, please complete another form like this one. Federal law says you must provide the information below. [42 U.S.C. § 666(a)(13)] It will only be used to collect child support. Child's first name Child's middle name Child's last name Date of birth Male/ female Social Security number

OKDHS issued 10-20-2006

03EN003E

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03EN003E

Summary of Support Order No Phone City father State mother Zip code other (name/address)

6. An income assignment is immediately ordered: Yes The employer of the person ordered to pay support is: Employer name Mailing address 7. Child(ren) health insurance provided by 8.

ordered to pay $ per month for $ per month for 9. Additional information: Obligor (The person ordered to pay support, the noncustodial parent): Date of birth M/F Social Security no. Daytime phone Employer phone Obligee (The person receiving support, the custodial person): Date of birth M/F Social Security no. Daytime phone Employer phone

(name of person) was also ____________ (payment type) (payment type)

10. Mailing Information: Obligor (The person ordered to pay support, the noncustodial parent): What is the mailing address to receive mail, to serve orders, and for notices to come to court? [Address of record ­ 43 O.S. § 112A] Street or P.O. Box address City State Zip code

Obligee (The person receiving support, the custodial person): What is the mailing address to receive mail, to serve orders, and for notices to come to court? [Address of record ­ 43 O.S. § 112A] Street or P.O. Box address City State Zip code Obligee: Do payments go to a different address? Write it here: Street or P.O. Box address City State Zip code

PREPARED BY DATE PRINT NAME PHONE

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OKDHS issued 10-20-2006