Fill and Sign the Oklahoma Child Support Services Form

IN THE DISTRICT COURT OF COUNTY STATE OF OKLAHOMA ) Petitioner/plaintiff ) ) and ) ) Respondent/defendant Case no: OCSS FGN: (Oklahoma Child Support Services ) case number) Summary of Support Order Mail to: OCSS, Central Case Registry, P. O. Box 248843, Oklahoma City, OK 73124-8843 or fax to: (405) 522-8901 This form must be completed and presented to the judge before the judge signs your order. The Oklahoma Child Support Services Central Case Registry needs this information to send child support payments. This form will NOT be put on file in the Courthouse. [43 O.S. § 120] 1. The judge made the following order: Temporary or Final on / /(date). What kind of case was heard by the judge? Divorce; Paternity; Juvenile; Modification of earlier order; Enforcement of earlier order; or Other type of case, explain: 2. Active Protective Order? Yes No 3. The judge made the fo llowing support orders: Amount Payor Begin date End date Child support Cash medical Fixed medical support Spousal support Arrearage payment Other: Total: 4. The judge ordered father, (name), or mother of the child(ren), (name), to provide health insurance for the child(ren), OR cash medical support in lieu of insu rance because health insurance is not available at a reasonable cost. The judge said cash medical support should be discontinued when the child(ren) is enrolled in health insurance at a reasonable cost not to exceed $ . 5. Please fill in the boxes below about each child that the judge ordered support to be paid for in this court order. If ther e are more than four children, please complete another form. Federal law requires you to provide the info rmation below. [42 U.S.C. § 666(a)(13)] Form 03EN003E revised 4-29-2010 may continue on next page, page 1 of 2 Child's first name Middle name Last name Date of birth Male/ female Social Security number 6. An income assignment is immediately ordered: Yes No The employer of the pers on ordered to pay support is: Employer name Area code Phone Street or P.O. Box mailing address City State Zip 7. Additional information: Obligor (The person ordered to pay suppor t, the noncustodial parent): Date of birth Male/Female Social Security number Daytime phone with area code Employer phone with area code Obligee (The person receiving suppor t, the custodial person): Date of birth Male/Female Social Security number Daytime phone with area code Employer phone with area code 8. Mailing information: Enter the mailing addres s to receive mail, to serve orders, and for notices to come to court. [Address of record – 43 O.S. § 112A] Obligor (The person ordered to pay suppor t, the noncustodial parent): Street or P.O. Box mailing address City State Zip Obligee (The person receiving suppor t, the custodial person): Street or P.O. Box mailing address City State Zip Should payments go to a diffe rent address for the Obligee? Yes No If yes, enter here: Street or P.O. Box mailing address City State Zip Date Prepared by Print name Area code and phone number Form 03EN003E revised 4-29-2010 may continue on next page, page 2 of 2