Superior Court of Washington

County of

I.  Judgment Summary

1.1       Judgment Summary for Non-Medical Expenses

            [ ]         Does not apply.

            [ ]         Applies as follows:

A.        Judgment creditor                                                                                                        

B.         Judgment debtor                                                                                                          

C.         Principal judgment amount (back child support/other obligations)                               $         

            from (date) ______________ through (date) ______________

D.        Interest to date of judgment                                                     $                                 

E.         Attorney fees                                                                           $                                 

F.         Costs                                                                                        $                                 

G.        Other recovery amount                                                            $                                 

H.        Principal judgment shall bear interest at __________ % per annum

I.          Attorney fees, costs and other recovery amounts shall bear interest at _______% per annum

J.          Attorney for judgment creditor                                                                                    

K.        Attorney for judgment debtor                                                                                      

L.         Other:

1.2       Judgment Summary for Medical Support

            [ ]         Does not apply.

            [ ]         Applies as follows:

A.        Judgment creditor                                                                                                        

B.         Judgment debtor                                                                                                          

C.         Judgment for medical support                                                 $                                 

            from (date) ______________ through (date) ______________

D.        Interest to date of judgment                                                     $                                 

E.         Attorney fees                                                                           $                                 

F.         Costs                                                                                        $                                 

G.        Principal judgment shall bear interest at __________ % per annum

H.        Attorney fees, costs and other recovery amounts shall bear interest at ______ % per annum

I.          Attorney for judgment creditor                                                                                    

J.          Attorney for judgment debtor                                                                                                  

K.        Other

II.  Basis

2.1       Type of Proceeding

            This order is entered under a petition for dissolution of marriage or domestic partnership, legal separation, or declaration concerning validity:

            [ ]         decree of dissolution, legal separation or a declaration concerning validity.

            [ ]         order for modification of child support.

            [ ]         hearing for temporary child support.

            [ ]         order of adjustment.

            [ ]         order for modification of a custody decree or parenting plan.

            [ ]         other:

2.2       Child Support Worksheet

            The child support worksheet which has been approved by the court is attached to this order and is incorporated by reference or has been initialed and filed separately and is incorporated by reference.

2.3       Other

III. Findings and Order

It Is Ordered:

3.1       Child(ren) for Whom Support is Required

3.2       Person Paying Support (Obligor)

            Name (first/last):

            Birth date:

            Service Address:  (You may list an address that is not your residential address where you agree to accept legal documents.)

The Obligor Parent Must Immediately File With the Court and the Washington State Child Support Registry, and Update as Necessary, the Confidential Information Form Required by RCW 26.23.050.

            The Obligor Parent Shall Update the Information Required by Paragraph 3.2 Promptly After any Change in the Information.  The Duty to Update the Information Continues as long as any Support Debt Remains due Under This Order.

For purposes of this Order of Child Support, the support obligation is based upon the following income:

A.                 [ ]         Actual Monthly Net Income: $ _______________.

OR

B.         [ ]         Monthly net income after exclusion requiring findings:

Actual monthly gross income $ _______________ from which the court excludes $ _______________ because the court finds that the obligor earned that income from overtime or from second jobs beyond 40 hours per week averaged over a 12-month period to:

            [ ]         provide for a current family’s needs; or

            [ ]         retire past relationship debts; or

            [ ]         retire child support debt; and

that the income will cease when the obligor has paid off his or her debts. 

            Monthly net income after allowed exclusion:  $_________________.

OR

C.         [ ]         The net income of the obligor is imputed at $ _______________ because:

                        [ ]         the obligor’s income is unknown.

                        [ ]         the obligor is voluntarily unemployed.

                        [ ]         the obligor is voluntarily underemployed.

The amount of imputed income is based on the following information in order of priority. The court has used the first option for which there is information:

[ ]         current rate of pay.

[ ]         reliable historical rate of pay information.

[ ]         Past earnings when there is incomplete or sporadic information of the parent’s past earnings.

[ ]         minimum wage in the jurisdiction where the parent lives at full-time earnings because the parent:

[ ]         has a recent history of minimum wage jobs,

[ ]         recently came off public assistance, general assistance-unemployable, supplemental security income, or disability

[ ]         was recently released from incarceration, or

[ ]         is a high school student.

[ ]         Median Net Monthly Income Table.

[ ]         Other:

3.3       Person Receiving Support (Obligee)

            Name (first/last):

            Birth date:

            Service Address:  (You may list an address that is not your residential address where you agree to accept legal documents.)

The Obligee Must Immediately File With the Court and the Washington State Child Support Registry and Update as Necessary the Confidential Information Form Required by RCW 26.23.050.

            The Obligee Shall Update the Information Required by Paragraph 3.3 Promptly After any Change in the Information.  The Duty to Update the Information Continues as Long as any Monthly Support Remains Due or any Unpaid Support Debt Remains Due Under This Order.

For purposes of this Order of Child Support, the support obligation is based upon the following income:

A.                 [ ]         Actual monthly Net Income: $ _______________.

OR

B.                 [ ]         Monthly net income after exclusion requiring findings:

Actual monthly gross income $ _______________ from which the court excludes $ _______________ because the court finds that the obligee earned that income from overtime or from second jobs beyond 40 hours per week averaged over a 12-month period to:

[ ]         provide for a current family’s needs; or

[ ]         retire past relationship debts; or

[ ]         retire child support debt; and

that the income will cease when the obligee has paid off his or her debts. 

Monthly net income after allowed exclusion:  $_________________.

OR

C.                 [ ]         The net income of the obligee is imputed at $ _______________ because:

                        [ ]         the obligee’s income is unknown.

                        [ ]         the obligee is voluntarily unemployed.

                        [ ]         the obligee is voluntarily underemployed.

The amount of imputed income is based on the following information in order of priority. The court has used the first option for which there is information:

[ ]         current rate of pay;

[ ]         reliable historical rate of pay information;

[ ]         Past earnings when there is incomplete or sporadic information of the parent’s past earnings;

[ ]         minimum wage in the jurisdiction where the parent lives at full-time earnings because the parent:

[ ]         has a recent history of minimum wage jobs;

[ ]         recently came off public assistance, general assistance-unemployable, supplemental security income; or disability

[ ]         was recently released from incarceration, or

[ ]         is a high school student;

[ ]         Median Net Monthly Income Table.

            [ ]         Other:

            The obligor may be able to seek reimbursement for day care or special child rearing expenses not actually incurred.  RCW 26.19.080.

3.4       Service of Process

            Service of Process on the Obligor at the Address Required by Paragraph 3.2 or any Updated Address, or on the Obligee at the Address Required by Paragraph 3.3 or any Updated Address, may Be Allowed or Accepted as Adequate in any Proceeding to Establish, Enforce or Modify a Child Support Order Between the Parties by Delivery of Written Notice to the Obligor or Obligee at the Last Address Provided.

3.5       Transfer Payment

            The obligor parent shall pay the following amounts per month for the following child(ren):

            Name                                                                                         Amount

                                                                                                      $                                                   

                                                                                                      $                                                   

                                                                                                      $                                                   

                                                                                                      $                                                   

            Total Monthly Transfer Amount                                    $                                                   

            [ ]         The parents’ combined monthly net income exceeds $12,000 and the court sets child support in excess of the presumptive amount for $12,000 because:

            [ ]         The court finds that the obligor’s child support obligations owed for all his or her biological or legal children exceed 45% of his or her net income and it is [ ] just
[ ] unjust to apply the 45% limitation based upon the best interests of the child(ren) and the circumstances of each parent as follows:

            [ ]         If one of the children changes age brackets, the child support shall be as follows:

            [ ]         This is a downward modification that has caused an overpayment of $ ______________.  This amount shall be repaid or credited as follows:

            [ ]         This is an upward modification that has caused an underpayment of $______________.  This amount shall be paid as follows:

            [ ]         Other:

            The Obligor Parent’s Privileges to Obtain or Maintain a License, Certificate, Registration, Permit, Approval, or Other Similar Document Issued by a Licensing Entity Evidencing Admission to or Granting Authority to Engage in a Profession, Occupation, Business, Industry, Recreational Pursuit, or the Operation of a Motor Vehicle may Be Denied or may Be Suspended if the Obligor Parent is not in Compliance With This Support Order as Provided in Chapter 74.20A Revised Code of Washington.

3.6       Standard Calculation

            $                                                         per month.  (See Worksheet line 17.)

3.7       Reasons for Deviation From Standard Calculation

[ ]   The child support amount ordered in paragraph 3.5 does not deviate from the standard calculation.

[ ]   The child support amount ordered in paragraph 3.5 deviates from the standard calculation for the following reasons:

      [ ]   Income of a new spouse or new domestic partner of the parent requesting a deviation for other reasons;

      [ ]   Income of other adults in the household of the parent requesting a deviation for other reasons;

      [ ]   Child support actually paid or received for other child(ren) from other relationships;

      [ ]   Gifts;

      [ ]   Prizes;

      [ ]   Possession of wealth;

      [ ]   Extraordinary income of child(ren);

      [ ]   Tax planning which results in greater benefit to the child(ren);

      [ ]   Income from overtime or second jobs that was excluded from income of the parent requesting a deviation for other reasons;

      [ ]   A nonrecurring source of income;

      [ ]   Extraordinary debt not voluntarily incurred;

      [ ]   A significant disparity in the living costs of the parents due to conditions beyond their control;

      [ ]   Special needs of disabled child(ren);

      [ ]   Special medical, educational, or psychological needs of the child(ren);

      [ ]   The child(ren) spend(s) a significant amount of time with the parent who is obligated to make a support transfer payment.  The deviation does not result in insufficient funds in the receiving parent’s household to meet the basic needs of the child(ren).  The child(ren) do(es) not receive public assistance;

      [ ]   Child(ren) from other relationships;

      [ ]   Costs incurred or anticipated to be incurred by the parents in compliance with court-ordered reunification efforts or under a voluntary placement agreement with an agency supervising the child(ren);

      [ ]   The obligor has established that it is unjust to apply the presumptive minimum payment of $50.00 per child;

      [ ]   The obligee has established that it is unjust to apply the self-support reserve.

      [ ]   Other reason(s) for deviation:

                  The factual basis for these reasons is as follows:

3.8       Reasons why Request for Deviation Was Denied

            [ ]         Does not apply. A deviation was ordered.

            [ ]         A deviation was not requested.

            [ ]         The deviation sought by the [ ] obligor [ ] obligee was denied because:

                        [ ]         no good reason exists to justify deviation.

                        [ ]         other:

3.9       Starting Date and Day to Be Paid

            Starting Date:                                     ________________________

            Day(s) of the month support is due:  ________________________

3.10    Incremental Payments

            [ ]         Does not apply.

            [ ]         This is a modification of child support.  Pursuant to RCW 26.09.170 (9)(a) and (c), the obligation has been modified by more than 30 percent and the change would cause significant hardship.  The increase in the child support obligation set forth in Paragraph 3.5 shall be implemented in two equal increments, one at the time of this order and the second on (date) _______________ six months from the entry of this order.

3.11    Making Support Payments

Select Enforcement and Collection, Payment Services Only, or Direct Payment:

            [ ]         Enforcement and collection:  The Division of Child Support (DCS) provides support enforcement services for this case because:   [ ] this is a public assistance case, [ ] this is a case in which a parent has requested services from DCS, [ ] a parent has signed the application for services from DCS on the last page of this support order.  (Check all that apply.)  Support payments shall be made to:

                                    Washington State Support Registry

                                    P. O. Box 45868

                                    Olympia, WA  98504

                                    Phone: 1-800-922-4306 or

                                                1-800-442-5437

            [ ]         Payment services only:  The Division of Child Support will process and keep a record of all payments but will not take any collection action.  Support payments shall be made to:

                        Washington State Support Registry

                        P. O. Box 45868

                        Olympia, WA  98504

                        Phone: 1-800-922-4306 or

                                    1-800-442-5437

            [ ]         Direct Payment:  Support payments shall be made directly to:

                        Name                                                                

                        Mailing Address                                                

                        ________________________________________

            A party required to make payments to the Washington State Support Registry will not receive credit for a payment made to any other party or entity.  The obligor parent shall keep the registry informed whether he or she has access to health insurance coverage at reasonable cost and, if so, to provide the health insurance policy information.

            Any time the Division of Child Support is providing support enforcement services under
RCW 26.23.045, or if a party is applying for support enforcement services by signing the application form on the bottom of the support order, the receiving parent might be required to submit an accounting of how the support, including any cash medical support, is being spent to benefit the child(ren).

3.12    Wage Withholding Action

            Withholding action may be taken against wages, earnings, assets, or benefits, and liens enforced against real and personal property under the child support statutes of this or any other state, without further notice to the obligor parent at any time after entry of this order unless an alternative provision is made below:

            [If the court orders immediate wage withholding in a case where Division of Child Support does not provide support enforcement services, a mandatory wage assignment under Chapter 26.18 RCW must be entered and support payments must be made to the Support Registry.]

            [ ]         Wage withholding, by notice of payroll deduction or other income withholding action under Chapter 26.18 RCW or Chapter 74.20A RCW, without further notice to the obligor, is delayed until a payment is past due, because:

                        [ ]         the parties have reached a written agreement that the court approves that provides for an alternate arrangement.

                        [ ]         the Division of Child Support provides support enforcement services for this case [see 3.11] and there is good cause [as stated below under "Good Cause"] not to require immediate income withholding which is in the best interests of the child(ren) and, in modification cases, previously ordered child support has been timely paid.

                        [ ]         the Division of Child Support does not provide support enforcement services for this case [see 3.11] and there is good cause [as stated below under "Good Cause"] not to require immediate income withholding.

                        Good Cause:

3.13    Termination of Support

            Support shall be paid:

            [ ]         provided that this is a temporary order, until a subsequent child support order is entered by this court.

            [ ]         until the child(ren) reach(es) the age of 18 or as long as the child(ren) remain(s) enrolled in high school, whichever occurs last, except as otherwise provided below in Paragraph 3.14.

            [ ]         until the child(ren) reach(es) the age of 18, except as otherwise provided below in Paragraph  3.14.

            [ ]         after the age of 18 for (name) ______________________________ who is a dependent adult child, until the child is capable of self-support and the necessity for support ceases.

            [ ]         until the obligation for post secondary support set forth in Paragraph 3.14 begins for the child(ren).

            [ ]         Other:

3.14    Post Secondary Educational Support

            [ ]         The right to request post secondary support is reserved, provided that the right is exercised before support terminates as set forth in paragraph 3.13.

            [ ]         The parents shall pay for the post secondary educational support of the child(ren).  Post secondary support provisions will be decided by agreement or by the court.

            [ ]         No post secondary educational support shall be required.

            [ ]         Other:

3.15    Payment for Expenses not Included in the Transfer Payment

            [ ]         Does not apply because all payments, except medical, are included in the transfer payment.

            [ ]         The petitioner shall pay __________% and the respondent __________ % (each parent’s proportional share of income from the Child Support Schedule Worksheet, line 6) of the following expenses incurred on behalf of the child(ren) listed in Paragraph 3.1:)

                        [ ]         day care.

                        [ ]         educational expenses.

                        [ ]         long distance transportation expenses.

                        [ ]         other:

                        Payments shall be made to [ ] the provider of the service [ ] the parent receiving the transfer payment.

            [ ]         The obligor shall pay the following amounts each month the expense is incurred on behalf of the child(ren) listed in Paragraph 3.1:

                        [ ]         day care: $ _______________ payable to the [ ] day care provider [ ] other parent;

                        [ ]         educational expenses: $ _______________ payable to the [ ] educational provider [ ] other parent;

                        [ ]         long distance transportation: $ _______________ payable to the

                                    [ ] transportation provider [ ] other parent.

                        [ ]         other:

3.16    Periodic Adjustment

            [ ]         Does not apply.

            [ ]         Child support shall be adjusted periodically as follows:

            [ ]         Other:

3.17    Income Tax Exemptions

            [ ]         Does not apply.

            [ ]         Tax exemptions for the child(ren) shall be allocated as follows:

            [ ]         The parents shall sign the federal income tax dependency exemption waiver.

            [ ]         Other:

3.18    Medical Support – Health Insurance

Each parent shall provide health insurance coverage for the child(ren) listed in paragraph 3.1, as follows:

3.18.1  Health Insurance (either check box A(1), or check box A(2) and complete sections B and C.  Section D applies in all cases.)

A.        Evidence

            (1) [ ]   There is insufficient evidence for the court to determine which parent must provide coverage and which parent must contribute a sum certain. Therefore, the court is not specifying how insurance coverage shall be provided.  The petitioner’s and respondent’s medical support obligations may be enforced by the Division of Child Support or the other parent under RCW 26.18.170 as described in paragraph 3.18.2, below.

OR

(2) [ ]   There is sufficient evidence for the court to determine which parent must provide coverage and which parent must contribute a sum certain.  Fill in B and C below.

B.         Findings about insurance:

[ ]         Does not apply because A (1) is checked, above.

[ ]         The court makes the following findings:

C.         Parties’ obligations:

[ ]         Does not apply because A (1) is checked above.

[ ]         The court makes the following orders:

D.        Both parties’ obligation:

If the child(ren) are receiving state financed medical coverage, the Division of Child Support may enforce the responsible parent’s monthly premium.

The parent(s) shall maintain health insurance coverage, if available for the child(ren) listed in paragraph 3.1, until further order of the court or until health insurance is no longer available through the parents’ employer or union and no conversion privileges exist to continue coverage following termination of employment. 

A parent who is required under this order to provide health insurance coverage is liable for any covered health care costs for which that parent receives direct payment from an insurer.

A parent who is required under this order to provide health insurance coverage shall provide proof that such coverage is available or not available within 20 days of the entry of this order to the other parent or the Washington State Support Registry if the parent has been notified or ordered to make payments to the Washington State Support Registry.

If proof that health insurance coverage is available or not available is not provided within 20 days, the parent seeking enforcement or the Department of Social and Health Services may seek direct enforcement of the coverage through the other parent’s employer or union without further notice to the other parent as provided under Chapter 26.18 RCW.

3.18.2  Change of Circumstances and Enforcement

A parent required to provide health insurance coverage must notify both the Division of Child Support and the other parent when coverage terminates.

If the parents’ circumstances change, or if the court has not specified how medical support shall be provided, the parents’ medical support obligations will be enforced as provided in
RCW 26.18.170.  If a parent does not provide proof of accessible coverage for the child(ren) through private insurance, a parent may be required to satisfy his or her medical support obligation by doing one of the following, listed in order of priority:

1)      Providing or maintaining health insurance coverage through the parent’s employment or union at a cost not to exceed 25% of that parent’s basic support obligation;

2)      Contributing the parent’s proportionate share of a monthly premium being paid by the other parent for health insurance coverage for the child(ren) listed in paragraph 3.1 of this order, not to exceed 25% of the obligated parent’s basic support obligation; or

3)      Contributing the parent’s proportionate share of a monthly premium paid by the state if the child(ren) receives state-financed medical coverage through DSHS under RCW 74.09 for which there is an assignment.

A parent seeking to enforce the obligation to provide health insurance coverage may apply for support enforcement services from the Division of Child Support; file a motion for contempt (use form WPF DRPSCU 05.0100, Motion/Declaration for an Order to Show Cause re Contempt); or file a petition.

3.19    Uninsured Medical Expenses

Both parents have an obligation to pay their share of uninsured medical expenses. 

The petitioner shall pay __________% of uninsured medical expenses (unless stated otherwise, the petitioner’s proportional share of income from the Worksheet, line 6) and the respondent shall pay ___________% of uninsured medical expenses (unless stated otherwise, the respondent’s proportional share of income from the Worksheet,
line 6).

3.20    Back Child Support

            [ ]         Back child support that may be owed is not affected by this order.

            [ ]         Back interest that may be owed is not affected by this order.

            [ ]         (Name) ___________________________________ is awarded a judgment against (name) __________________________ in the amount of $ _______________ for back child support for the period from (date) ____________ through (date) ______________.

            [ ]         (Name) _______________________________ is awarded a judgment against
(name) ____________________________ in the amount of $ _______________for back interest for the period from (date) ______________ through (date) ________________.

            [ ]         No back child support is owed at this time.

            [ ]         No back interest is owed at this time.

            [ ]         Other:

3.21    Past Due Unpaid Medical Support

            [ ]         Unpaid medical support that may be owed is not affected by this order.

            [ ]         Back interest that may be owed is not affected by this order.

            [ ]         (Name) ____________________________ is awarded a judgment against
(name) _________________________ in the amount of $ _______________for past due unpaid medical support for the period from (date) ________ through (date) ________.

            [ ]         (Name) __________________________ is awarded a judgment against
(name) ________________________ in the amount of $ _______________for back interest for the period from (date) ______________ through (date) _______________.

            [ ]         No past due unpaid medical support is owed at this time.

            [ ]         No back interest is owed at this time.

            [ ]         Other:

3.22    Other Unpaid Obligations

            [ ]         Other obligations that may be owed are not affected by this order.

            [ ]         Back interest that may be owed is not affected by this order.

[ ]         (Name) ________________________________ is awarded a judgment against
(name) _________________________ in the amount of $ _______________for [ ] child care [ ] ordered contributions to extracurricular activities [  ] long distance transportation costs [ ] educational expenses [ ] post secondary [ ] other _________________________
 for the period from (date) ______________ through (date) ___________________.

            [ ]         (Name) ________________________ is awarded a judgment against
(name) _______________________  in the amount of $ _______________for back interest for the period from (date) ______________ through (date) ________________.

[ ]         No other obligations are owed at this time.

            [ ]         No back interest is owed at this time.

            [ ]         Other:

3.23    Other

Dated:                                                                                                                                                 

                                                                                    Judge/Commissioner

Presented by:                                                               Approved for entry:

                                                                                    Notice of presentation waived:

Signature of Party or Lawyer/WSBA No.                     Signature of Party or Lawyer/WSBA No.

Print Name                                                                   Print Name

[ ]         I apply for full support enforcement services from the DSHS’ Division of Child Support (DCS).

            (Note:  If you never received TANF, tribal TANF, or AFDC, an annual $25 fee applies if over $500 is disbursed on a case, unless the fee is waived by DCS.)

            Signature of Party

[ ]         Approval required in Public Assistance cases.   The DSHS’ Division of Child Support received notice required by RCW 26.23.130. This order has been reviewed and approved as to:

            [ ]  Current Child Support

            [ ]  Back Child Support

            [ ]  Medical Support

            [ ]  Other:

                                                  ____________________________________________

                                                  Deputy Prosecuting Attorney/WSBA No.