Vermont Child Support Order Form

01 Jul, 2017 Divorce, Legal Forms, vermont 0

Upon the finalization of the divorce, the spouse named in this Order will be required to pay for child support. Also indicated in the Order are the specific details regarding the amount and schedule of the payments.Download

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Page 1

Docket Number

County

Vermont

Family Court
IN THE MATTER OF:

Plaintiff

VS.

Defendant
OBLIGOR'S EMPLOYER

OBLIGOR (Person Who Must Pay Support)

First Name
Last Name
Initial
Name
Street Address

Street Address
State

City
Zip Code

State

City
Zip Code
Telephone Number

Telephone Number

Date of Birth

Social Security Number
OBLIGEE'S EMPLOYER

OBLIGEE (Person Who Receives Support)

Initial
Last Name
First Name
Name
Street Address

Street Address
City

Zip Code

State
State

City
Zip Code
Telephone Number

Telephone Number
Date of Birth

Grade
Social Security Number

Last Name
First Name
M.
Last Name

First Name
Date of Birth
Grade
Social Security Number

M.
Date of Birth

Social Security Number

Last Name
First Name

M.
Grade
Date of Birth

Grade
Social Security Number

Last Name First NameLast Name

M.
Date of Birth
Grade
Social Security Number

First Name
Last Name

Date of BirthGrade
Social Security Number

First Name
M.

Rev. 7/06 SML
M.

Form 802
CHILD SUPPORT ORDER

Date of Birth

Social Security Number
CHILDREN WHO ARE SUBJECT TO THIS ORDER:

Page 2

DOCKET NO.

CHILD SUPPORT ORDER

This order is entered upon
default (failure to file an answer)

after default hearing (when one or more parties fail to appear)
after hearing (when parties are present and/or represented by counsel)

approval of the parties (stipulation filed)
FINDINGS AND BASIS OF ORDER

Physical responsibility for the child(ren) for the purpose of child support is:

primarily with
with

split as follows: Child(ren):

name of parent

with

Child(ren):

name of parent

% of time with

shared as follows:

name of parent

% of time with
name of parent

B)
a stipulation of the parties dated

Physical responsibility is based on:

an Order of the Court dated

is/are in the custody of others.

Child(ren)

Additional information:

D)
III. CURRENT CHILD SUPPORT

This is the result of a child support worksheet which is attached and incorporated as Findings in this Order and which
includes information on other child support related costs, such as child care, extraordinary medical and/or educational

expenses.
ORDER

the Obligor shall pay child support in the amount of

Beginning Date:

per time period:

the Obligor shall pay child support maintenance supplement in the amount of

B)
I. TYPE OF HEARING, DEFAULT OR STIPULATION
II. PARENTAL RIGHTS AND RESPONSIBILITIES

Beginning Date:
per time period:

$
Rev. 7/06 SML

CHILD SUPPORT ORDER
DOCKET NO.

Page 3

IV. ARREARS ON PAST DUE CHILD SUPPORT/REPAYMENT PROVISIONS
A)

ARREARS OWED TO THE OFFICE OF CHILD SUPPORT:

the obligor shall pay the Office of Child Support the sum of
towards a judgment in the amount of

This judgment consists of past due support

as of (date):

; medical expenses
; service fees

civil penalty
; Attorney fees

; other

B)
ARREARS OWED TO THE OBLIGEE:

the obligor shall pay to the obligee

towards a judgment in the amount of

This judgment consists of past due support ; medical expenses

; service fees
; civil penalty

Attorney fees

ARREARS OWED TO ANOTHER PERSON OR AGENCY:
the obligor shall pay to the

towards a judgment in the amount of

ADDITIONAL:

V. METHOD OF PAYMENT
A) WAGE WITHHOLDING ORDER

any employer of the Obligor shall deduct the sum of

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 Protection Act.)
as of (date):

Beginning Date:

$
per (time period):

$ $ $$
$ $

Beginning Date:

per (time period):
$
$
$
$ $
$
$

Beginning Date:
$
per (time period):

$
as of (date):
.
1) Beginning Date:

$
per (time period):
$

Rev. 7/06 SML
D)
; surcharge

; surcharge
$

2) At any time 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
the 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).

cash contribution toward medical $

;
; ;
;

; other
$

cash contribution toward medical $

CHILD SUPPORT ORDER
DOCKET NO. Page 4

B) DIRECT PAYMENT - Based upon: 1) Stipulation of the parties or
2) Evidence presented at hearing

the Obligor shall pay the sum of

to the Office of Child Support. This amount shall be paid directly to:

the Obligor shall pay the sum of

to the Obligee.

(NOTE: If the court finds, after a hearing on a petition, that any support payment has been late by 7 days or

more, the court may issue a wage withholding order, pursuant to 15 V.S.A. section 782.)
VI. MEDICAL SUPPORT
1) Beginning Date:

per (time period):

2) Beginning Date:
per (time period):
$
$

Rev. 7/06 SML
OFFICE OF CHILD SUPPORT, PO BOX 1310, WILLISTON, VT 05495
A. Health Insurance -

CALCULATION TO DETERMINE REASONABLE COST - FINDINGS

1. Private health insurance is available to: Obligee Obligor Neither

2. Private health insurance is deemed reasonable for: obligee obligor because:
the cost of health insurance is 5% or less of a parent's gross income as calculated above for obligee obligor.
the cost of health insurance is in excess of 5% of a parent's gross income and the court has considered the factors of
15 V.S.A. § 659.
Additional findings:

3. Although the cost of health insurance is 5% or less of a parent's gross income, the
obligee obligor is not required to provide health insurance for the following reasons:

1) The obligor obligee is ORDERED to provide and maintain private health insurance for the minor child(ren) because the cost
for health insurance is deemed reasonable pursuant to the findings set forth above; OR

2) 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.

3) Beginning Date: the Obligor shall pay a cash contribution toward the cost of health coverage in the
amount of $ per (time period): .

CURRENT MEDICAL SUPPORT COVERAGE

B. 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/split as follows:
% Obligor % Obligee
$
$
$
$
$
$
Private health insurance. Name of Subscriber: Relationship to Child(ren)
Plan Name and Address Subscriber's I.D. Number
MEDICAL SUPPORT ORDER
Policy or Certificate Number Obligee
Obligor
Gross monthly income is
5% gross monthly income is
Total monthly health insurance premium is

CHILD SUPPORT ORDER

DOCKET NO.
Page 5

1) If employed, a parent under a medical support order shall notify his/her employer of such obligation, in writing, within
10 days of the date of this order.

2) If self-employed or unemployed, a parent under a medical support order shall notify his/her health care insurer of such
obligation in writing within 10 days of the date of this order.

3) A parent is liable for any unreimbursed health care costs of the child(ren) that result from a parent's failure to give notice/obtain insurance as ordered above, which accrues between the date of this order and the date that the order is

modified by the Court.

4) If a parent has health insurance through an entity other than his/her employer, that parent shall be responsible for maintaining that insurance and complying with any notice requirements under the policy in effect. Failure to do so will
make the parent liable for paying any unreimbursed health care expenses that accrue between the date of this order and

the date this order is modified by the Court.

5) If a parent pays a health expense of a child subject to this order and the other parent receives reimbursement from insurance for the expense, the reimbursement shall be sent to the parent who advanced payment, within 7 days of receipt.

If the child(ren) also have Medicaid coverage, payment is to be sent to the: Office of Health Access

312 Hurricane Drive, Suite 201, Williston, VT 05495-2806, within 7 days.

6) The parties shall provide each other with copies of bills for health expenses and documentation of insurance determination within 7 days of receipt. The parent who maintains insurance shall also provide the other parent with a health insurance

card, claim forms and a list of benefits and restrictions within 10 days of the date of this order.

7) Each party shall notify the: Office of Child Support, Support Registry, 103 South Main Street, Waterbury, VT 05671-1901
within 7 days of a change in address, employment or health insurance carrier. This notification requirement applies until

all obligations to support arrearages or orders to provide visitation are satisfied.
ADDITIONAL FINDINGS

A Relief from Abuse Order exists for these parties under Docket No.

B)
A party's address is omitted for confidentiality purposes after a court finding of good cause.

Other:

C)
VII. ADDITIONAL FINDINGS AND ORDER

Rev. 7/06 SML A PARENT OR ANY OTHER PERSON TO WHOM SUPPORT HAS BEEN GRANTED, OR ANY PERSON CHARGED
WITH SUPPORT, MAY FILE A MOTION FOR A MODIFICATION OF A CHILD SUPPORT ORDER UNDER 15 VSA
SECTION 660. A MODIFICATION MAY BE GRANTED UPON A REAL, SUBSTANTIAL, AND UNANTICIPATED
CHANGE OF CIRCUMSTANCES, INCLUDING LOSS OF EMPLOYMENT OR A CONSIDERABLE REDUCTION OR
INCREASE IN SALARY OR WAGES. AN OBLIGOR IS RESPONSIBLE FOR ANY REQUIRED PAYMENTS SET
FORTH IN AN ORDER UNLESS THE ORDER IS VACATED OR MODIFIED BY A COURT. THUS, ANY
SUBSEQUENT AGREEMENT BETWEEN THE PARTIES THAT DIFFERS FROM THE ORDER IS NOT LEGALLY
BINDING, AND THE OBLIGOR IS STILL LEGALLY REQUIRED TO PAY THE AMOUNT ORDERED BY THE COURT.
(15 VSA, Section 663 (e)).
8)

C) Additional Orders:

Page 6

CHILD SUPPORT ORDER DOCKET NO.
VIII. DURATION OF CHILD SUPPORT

A) This order shall remain in effect unless and until it is changed or discontinued by further order of the Court or operation of law.
B) Unless otherwise specified, an Obligor's support obligation will continue beyond a child's eighteenth birthday if the child is
enrolled in, but has not completed high school.

C) If wage withholding is ordered and an arrearage exists when the support obligation terminates, the monthly current
obligation and any arrearage repayment plan shall not be reduced until the amount is satisfied. The above is stipulated by the parties.

Date

Signature of Obligee

Signature of Obligor

Approved as to Form

Signature of Obligor's Attorney

Date
Date

Signature of Obligee's Attorney

Date

OCS Representative

Date

Magistrate/Presiding Judge

It is so ORDERED.

Assistant Judge

Assistant Judge
Date
Date

ACCEPTANCE OF SERVICE

I have received a copy of this Order and I waive all other service.

Date

Obligee
Date

Obligor

NOTICE OF RIGHT TO APPEAL

An order signed by the Magistrate or Presiding Judge may be appealed by filing a Notice of Appeal with the Clerk of the

Family Court within 30 days of filing of this order.

Rev. 7/06 SML

CHILD SUPPORT ORDER

Page 7

DOCKET NO.

NOTICE OF A PARENT'S RESPONSIBILITY AND RIGHTS

THIS IS A COURT ORDER

All parties are expected to comply with all terms of this Order.

The address provided to the Court shall remain the same for service of future actions and/or orders unless a parent notifies the court

of a change.

A PARTY HAS THE RIGHT TO SEEK MODIFICATION OF THE ORDER BY FILING AN ACTION IN COURT

RIGHT TO SEEK ENFORCEMENT OF THE ORDER
1. A party may place liens on real or personal property.
2. A party may request the Court to:
a) place assets in escrow.

b) suspend any and all licenses owned by the Obligor. This may include, but is not limited to, professional, hunting,
fishing, or motor vehicle driver's licenses.

c) grant a civil penalty when noncompliance of the support is willful. d) order wage withholding if the support amount is at least 7 days delinquent.
e) find the Obligor in Contempt if there is willful noncompliance with this order.

IN ADDITION TO THE REMEDIES LISTED ABOVE:

A party has the right to request assistance from the Vermont Office of Child Support in the effort to enforce this Order. If the Officeof Child Support is or becomes involved in this case, based either on a current or future request for their services, or otherwise, the

Office is not limited to but may take the following steps when appropriate:

1. Use any lawful collection remedies to collect any outstanding balance from the Obligor, regardless of any repayment plan on any
unpaid debts.

2. Certify all qualifying child support debts to the Vermont Tax Department and/or the Federal Treasury Offset Program for the
purpose of intercepting tax returns and/or other payments (i.e., vendor payments, passport denial, etc.)

3. Report an Obligor's account balance to consumer credit reporting agencies and/or request a copy of the report.

4. Administratively issue a wage withholding order for current support and/or arrearages in excess of l/12 of the annual support
obligation.

5. Freeze bank accounts and take the proceeds to satisfy past due support.

Rev. 7/06 SML
A party has the right to request a modification of the child support order based upon a real, substantial, unanticipated change of
circumstances or if the support amount has not been modified by the Court for at least three years from the date of the last order.

f) impose surcharges on past due child support.

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Vermont Child Support Order Form

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