Kentucky Judicial Redistricting Plan

UNIFORM CHILD SUPPORT ORDER AND/OR WAGE/INCOME WITHHOLDING ORDER

* See Footnotes & Additional Information

NOTICE: The Federal Income Withholding For Support Form OMB 0970-0154 must be used by private parties or their attorneys in non-IV-D eligible cases to notify an employer/income withholder of any wage/income withholding ordered herein.

In Re: Child's Name

Social Security No. Birthdate

Child's Name

Social Security No. Birthdate

If there are more than two (2) children, attach separate sheet with identifying information and check here Said attachment is incorporated into this Order by reference.

IT IS HEREBY ORDERED AND ADJUDGED THAT: The Mother Father Other

shall pay child support as follows:

1) $ per month as current child support effective

As determined by KY Child Support Guidelines;

By written agreement of parties with knowledge of the Guidelines;

Upon a finding that application of the Guidelines would be unjust or inappropriate because:

2) $ per month toward arrearage judgment totaling $ calculated for period beginning and ending

3) Health insurance is currently accessible and reasonable in cost. The Mother Father is ordered to provide and maintain health insurance coverage for the minor child(ren).

Health insurance is not currently accessible and reasonable in cost but shall be provided by the Mother Father when it becomes accessible and reasonable in cost. Extraordinary medical expenses shall be paid as follows:

4) $ per month for other expenses:

5) $ TOTAL MONTHLY AMOUNT to be paid at: ¹ $ per week bi-weekly semi-monthly month

6) Other conditions:

¹ If child support is paid by wage withholding, a job change may affect the frequency and amount of wages to be withheld in order to meet the monthly obligation amount.

² Child support recipient may elect not to provide address information in this section but in order to be properly disbursed his/her mailing address must be provided to the child support agency.

CHILD SUPPORT SHALL CONTINUE IN FULL FORCE AND EFFECT UNLESS MODIFIED BY THE COURT, OR ENDED BY OPERATION OF LAW.

7) Check only box A, B, or C as appropriate and any applicable options therein.

A. Child support ordered herein shall be subject to wage/income withholding on the effective date of this Order, to begin immediately. ³ The employee is responsible for making payments to recipient: (check one)

directly, OR through until such time as child support is withheld from the employee's paycheck. This Order shall apply to any subsequent employer.

OR

B. One party has demonstrated and the Court hereby finds that there is good cause not to require immediate wage/income withholding. Child support shall be paid as follows: (check one)

Mailed directly to: Kentucky Child Support Enforcement at Centralized Collection Unit P.O. Box 14059, Lexington, KY 40512-4059

OR

Other:

Wage/Income withholding shall take effect when an arrearage accrues that is equal to the amount of support payable for one month without the need for a judicial or administrative hearing. If wage/income withholding becomes applicable, see footnotes 3, 4, and 5 below relating to the mandatory federal income withholding form.

OR

C. The Court has made a finding that both parties have reached a written agreement which provides for an alternative arrangement to wage/income withholding as follows:

³ Effective June 1, 2012, the Federal Income Withholding For Support Form OMB 0970-0154 must be used by private parties or their attorneys in non-IV-D eligible cases to notify an employer/income withholder of any wage/income withholding ordered herein.

⁴ All child support payments made pursuant to a wage/income withholding order shall be directed to the State Disbursement Unit at: Kentucky Child Support Enforcement at Centralized Collection Unit, P.O. Box 14059, Lexington, KY 40512-4059.

⁵ Requesting party must mail Form OMB 0970-0154 and a copy of this Order, AOC-152, by certified mail to the employer within 2 working days.

Notice. Obligor: Interest may be charged on any delinquent child support payments. KRS 360.040 and 405.467(2).

This order reflects statutory provisions of KRS 403.211-.212, 405.467, 360.040, 405.465, 205.710, 205.712, 403.215, 403.750, and 610.170, the provisions of FCRPP 9, and section 466 of the Social Security Act.

Distribution: Court File - Original. CHFS (place in Contracting Official's basket). Petitioner. Respondent.