Vermont > Statewide > Family Court
Child Support Order 802 - Vermont
| Child Support Order Form. This is a Vermont form and can be used in Family Court Statewide . |
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Form 802 STATE OF VERMONT Page 1 SUPERIOR COURT Unit Plaintiff DOB V. FAMILY DIVISION Docket No. Defendant DOB INTERIM Establishment TEMPORARY Modification FINAL Enforcement DEFAULT Contempt CHILD SUPPORT ORDER OBLIGOR (Person Who Pays Support) Last Name First Name Initial OBLIGOR'S EMPLOYER or Source of Funds Name Mailing Address Mailing Address City Telephone Number Social Security Number Email Address State Zip Code City Telephone Number State Zip Code OBLIGEE (Person Who Receives Support) Last Name First Name Initial OBLIGEE'S EMPLOYER or Source of Funds Name Mailing Address Mailing Address City Telephone Number Social Security Number Email Address State Zip Code City Telephone Number State Zip Code CHILDREN WHO ARE SUBJECT OF THIS ORDER Last Name Last Name Last Name Last Name Last Name First Name First Name First Name First Name First Name M. M. M. M. M. Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Grade Grade Grade Grade Grade Social Security Number Social Security Number Social Security Number Social Security Number Social Security Number SML 4/12 American LegalNet, Inc. www.FormsWorkFlow.com · . . 1a 1 1 . Page 2 DOCKET NO CHILD SUPPORT ORDER I. CURRENT CHILD SUPPORT ·. This is the result of a child support worksheet which is attached and incorporated as findings in this order and includes information on other child support related costs, such as child care, extraordinary medical and/or educational expenses. A. Child Support: Obligor shall pay child support as follows: Beginning Date Amount $ Time Period per B. Child Support Maintenance Supplement: Obligor shall pay maintenance supplement as follows: Beginning Date Amount Time Period $ per C. Spousal Maintenance: Obligor shall pay spousal maintenance as follows: Beginning Date Amount Time Period per II. MEDICAL SUPPORT This is the result of a medical support worksheet which is attached and incorporated as findings in this order. Neither party has private health insurance available to them. Medical support is addressed in the Child Support Order filed , and has not been modified by this order. A. The parties are ordered to pay medical support as follows: The Obligor Obligee is ORDERED to provide and maintain private health insurance for the minor child(ren) as long as the cost of health insurance is deemed reasonable. Private health insurance is currently unavailable to either party. the cost of health coverage as follows: $ The obligor shall pay a cash contribution toward Per Beginning: Private health insurance is currently unavailable to either parent at a reasonable cost. If private health insurance becomes available to either parent at a reasonable cost, that parent shall be responsible for providing and maintaining health insurance for the minor child(ren). Either parent may request a hearing to determine whether the cost of health insurance is reasonable. B. Current Medical Support Coverage Private health insurance: Policy or Certificate Number Name of Subscriber and Relationship to Children Plan Name and Address Subscriber ID Number C. Child(ren)'s Out of Pocket Medical Expenses Medical or other health expenses that are unreimbursed by insurance (including but not limited to expenses for eye, dental, mental health, health plan deductible) shall be shared as follows: 1) Obligee is solely responsible for the first $200 annually of the children's out of pocket health expenses. 2) The parties shall share unreimbursed expenses as follows: Obligor % Obligee 3) Additional Provisions: % SML 4/12 American LegalNet, Inc. www.FormsWorkFlow.com · . . 1a 1 1 . CHILD SUPPORT ORDER DOCKET NO Page 3 III. ARREARS ON PAST DUE CHILD SUPPORT/REPAYMENT PROVISIONS A. Arrears Owed to the Obligee Obligor shall pay the Obligee as follows: Beginning Date Amount $ Time Period per on a Judgment Amount $ Date as of The judgment consists of the following past due amounts: Past due support Surcharge Service fees Civil Penalty $ Other: Attorney Fees $ Amount of Other $ Medical Expenses $ $ Cash Contribution towards Medical $ B. Arrears Owed to Office of Child Support Obligor shall pay the Office of Child Support as follows: Beginning Date Amount $ Time Period Judgment Amount Date per Civil Penalty $ on a $ as of Other: Amount of Other $ The judgment consists of the following past due amounts: Child Support $ Service fees $ Cash Contribution towards Medical $ C. Arrears Owed to Another Person or Agency Name of Other Person or Agency Obligor shall pay to Beginning Date Amount $ Time Period Judgment Amount as follows: Date per on a $ as of The judgment consists of the following past due amounts: Past due support $ Other: Amount of Other $ D. Surcharge or Interest Surcharge or interest accrues on the unpaid balance of support at the rate of .5% per month or 6% per year from 1/1/12 forward until the support arrears are paid in full - even if the Obligor is making monthly arrears payments in conformity with this order. 15 V.S.A. § 606. Surcharge prior to 1/1/12 accrued at the rate of 1% per month. E. Arrears owed to the Obligee shall be paid first unless the Obligee is a recipient of federal public assistance benefits. F. Additional Arrears Provisions: SML 4/12 American LegalNet, Inc. www.FormsWorkFlow.com CHILD SUPPORT ORDER DOCKET NO. Page 4 IV. Method of Payment A. WAGE WITHHOLDING ORDER Any employer of the Obligor shall deduct the following sum from the Obligor's wages: Beginning date Amount to be deducted $ Time Period per This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT, PO BOX 1310, WILLISTON, VT 05495. (NOTE: This provision of this order is subject to the limits on withholding contained in 15 U.S.C. § 1673(b) and § 303(b) of the Consumer Credit Protection Act.) At any time if the child support obligation is not being paid through wage withholding, the responsible parent shall send the payments to the Office of Child Support or Obligee. (NOTE: Any direct payments made by the Obligor to the Obligee will not be reflected in OCS records unless OCS received written notification of the direct payment.) B. DIRECT PAYMENT Based upon Stipulation of the parties Beginning Date Evidence presented at hearing. Time Period Obligor shall make payments directly to the Office of Child Support as follows: Amount $ per This amount shall be paid directly to: OFFICE OF CHILD SUPPORT, PO BOX 1310, WILLISTON, VT 05495. Obligor shall make payments directly to the Obligee as follows: Beginning Date Amount Time Period $
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