Fill and Sign the Kentucky Judicial Redistricting Plan Kentucky Court of Justice Form

___ ________________________________________________________________________\ ____________________ ____________________________________________ ___________________________________________________ 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 id\ entifying information and check here [ ]. Said attachment is incorporated into this Order by reference. IT IS HEREBY ORDERED AND ADJUDGED THA T: The [ ] Mother [ ] Father [ ] Other _________________ ___________________________________________ shall pay child support as f\ ollows: 1) $___ _______ per month as current child support effective ____________________, ______: [ ] As determined by KY Child Support Guidelines; [ ] By written agreement of parties wit\ h knowledge of the Guidelines; [ ] Upon a finding that application of the Guidelines would be unjust or inappropriate because: __________________ ___ _________________________________________________ _______________________________________. 2) $____ ______ per month to ward arrearage judgment totaling $______________, calculated for period beginning _____ ____________________, ______ and ending ___________________________, ___\ ___. 3) [ ] Health insurance is currently accessible and reasonable in cost. The [ ] Mother [ ] Father is ordered t o 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 [ ] Mo\ ther [ ] 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: ____________________________________________________________\ _________________ _______ _________ ________________________________________________________________________\ _______. Case No.____________________ Court [ ] District [ ] Circuit [ ] Family County ______________________ IV-D Case No. ________________ AOC-152 Doc Code: OSUP Rev. 4-13 OSUPW Page 1 of 2 Commonwealth of KentuckyCourt of Justice www.courts.ky.gov * See Footnotes & Additional Information Plaintiff/Petitioner Name Birthdate SSN Defendant/Respondent Name Birthdate SSN NOTICE: The Federal Income Withholding For Support Form OMB 0970-0154 must be used by private partie\ s or their attorneys in non-IV-D eligible cases to notify an employer/income withholder of any wage/income withhol\ ding ordered herein. DOMESTIC VIOLENCE PROTECTIVE ORDER ISSUED [ ] YES [ ] NO PROTECTED PARTY: [ ] PETITIONER [ ] RESPONDENT Child Support Recipient's Name & Address 2 - _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ 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 i\ n this section but in order to be properly disbursed his/her mailing address must be provided to the child support agency. UNIFORM CHILD SUPPORT ORDER AND/OR WAGE/INCOME WITHHOLDING ORDER [ ] NEW ORDER [ ] AMENDED ORDER [ ] ORDER FOR WAGE/INCOME WITHH OLDING lex et justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE CHILD SUPPORT SHALL CONTINUE IN FULL FORCE AND EFFECT UNLESS MODIFIED by THE COURT , OR ENDED by OPERATION OF LAW . 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. Date: ____ _________________________, _______. _______________________________________ Judge AOC-152Rev. 4-13Page 2 of 2 Distribution: Court File – Original. CHFS (place in Contracting Official’s basket). Petitioner. Respondent. 7) Check only box A, B, or C as appropriate and any applicable options therein . A. [ ] Child su pport 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 ti me as child support is withheld from the employee’s paycheck. This Order shall apply to any subsequent employer. The Federal Income Withholding Support Form OMB 0970-0154 must be utilized by private partie\ s and attorneys in non-IV-D eligible cases, and must direct the employer to remit payment to the \ State Disbursement Unit. 4 Attach a copy of this Order, AOC-152, to Form OMB 0970-0154 when serving the employer. 5 OR B. [ ] One party has demonstrated and the Court hereby finds that there is good cause not to require immediate wage/i ncome withholding. Child support shall be paid as follows: (check one) [ ] Ma iled directly to: Kentucky Child Support Enforcement at Centralized Collection Unit P.O. Box 14059, Lexington, KY 40512-4059 OR [ ] Other: ________________________________________________________________________\ Wage/Inco me 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 f ootnotes 3, 4, and 5 below relating to the mandatory federal income with\ holding form. OR C. [ ] The Court has made a finding that both parties have reached a written agreement which provides for an alternative arrange ment 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 partie\ s or their attorneys in non-IV-D eligible cases to notify an employer/income withholder of any wage/in\ come withholding ordered herein. 4 All child support payments made pursuant to a wage/income withholding or\ der 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 Reque sting 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) . DOCUMENT PREPARER: _____________________________________________________________________ Address: _______________________________________________________________\ ____________________ ________________________________________________________________________\ ___________________ Phone No. __________________________________________________ *** For private non -iv-d eligible cases , preparer must send copy oF this order to: K entucKy child support enForcement , nivd u nit , p .o. b ox 2150 , F ranKFort , Ky 40602 F ax: (502) 564-7938