Cause Number _____________________________________
AG Case Number (if applicable)________________________ Should Income Withholding be Issued? ? Yes ? No Was start date prior to signing of order? ? Yes ? No
OBLIGEE: __________________________________________________ Soc. Sec. No: _______________________________ DOB: ____________ Drivers License No: _______________________________ ST: ________ Home Address: ______________________________________________
Court Number _____________
Temp Order Previously Issued? Modified Order? Existing Account? ? Yes ? Yes ? Yes ? No ? No ? No
OBLIGOR: __________________________________________________ Soc. Sec. No: _______________________________ DOB: ____________ Drivers License No: _______________________________ ST: ________ Home Address: ______________________________________________
_____________________________________________________________ County of Residence: ___________________________________________ Phone: (H)_________________________(W)________________________ Relationship to Child(ren): _________________________ Sex: M / F
_____________________________________________________________ County of Residence: ___________________________________________ Phone: (H)_________________________(W)________________________ Relationship to Child(ren): ________________________ Sex: M / F
Employer: ____________________________________________________ Address:_____________________________________________________ _____________________________________________________________ Is Obligor Incarcerated? YES___________ NO ____________ CHILD'S NAME
Employer: ____________________________________________________ Address:_____________________________________________________ _____________________________________________________________ DATE OF BIRTH SOCIAL SECURITY NUMBER SEX M/F M/F M/F M/F
Order Type: (circle one) Divorce
Paternity
SAPCR
Enforcement
CIRCLE ONE
Modification
Order Status: (circle one) Temporary
Final
Regular Child Support: $___________________ (monthly, semi-monthly, biweekly, weekly) beginning ______________________, 20_____ Decreases as children emancipate?: $_________ (monthly, semi-monthly, biweekly, weekly) $_________ (monthly, semi-monthly, biweekly, weekly) $_________ (monthly, semi-monthly, biweekly, weekly) $_________ (monthly, semi-monthly, biweekly, weekly) One time child support payment?: ______________________________ due _____________________________________, 20_________ Accrual Suspension: from ______________ through _____________________ every _______________ beginning __________________ Total Child Support Arrears: ____________________________ Calculated as of: __________________________________, 20_______ Child Support Arrears Payment: $__________________ (monthly, semi-monthly, biweekly, weekly ) beginning _________________, 20____ Payment increases as children emancipate? Yes__ No___ Lump Sum Arrearage Payment: $__________ due ___________, 20_____ $___________ (monthly, semi-monthly, biweekly, weekly) $________ due ___________, 20_____; $________ due _______, 20_____
$___________ (monthly, semi-monthly, biweekly, weekly) $________ due ___________, 20_____; $________ due _______, 20_____ Cash Medical Support: $____________________ (monthly, semi-monthly, biweekly, weekly) beginning ______________________, 20_____ Total Medical Support Arrears: __________________________ Calculated as of: ________________________________, 20_______ Medical Support Arrears Payment: $_________________ (monthly, semi-monthly, biweekly, weekly ) beginning ________________, 20____ Medical Insurance (circle one): Obligor provides Obligee provides Both Responsible Not addressed Cash Spousal Support: $____________________ (monthly, semi-monthly, biweekly, weekly) beginning ______________________, 20_____ Total Spousal Support Arrears: __________________________ Calculated as of: ________________________________, 20_______ Spousal Support Arrears Payment: $_________________ (monthly, semi-monthly, biweekly, weekly ) beginning ________________, 20____ Date of Hearing: __________________________
Obligee Attorney Phone
Date of Order____________________________
Obligor Attorney Phone
Form prepared by: _________________________________ Phone: ________________________ Date : _______________, 20_____ Obligee Signature: _______________________________________ Obligor Signature: ________________________________________ Attach additional forms if there are more children for this cause