Fill and Sign the Respondent Restrained Person Form

Page 1 of 4 Civil Rule 90.3 DV-101 (4/18)(cs) AS 25.27.062(a) CHILD SUPPORT INFORMATION AS 25.27.060(c) IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) PETITIONER (protected person), M F ) Birthdate: ) Petitioner is a child. Who is signing for the child? ) Name: Birthdate: ) Relationship to child: ) v. ) ) Case No. CI ) RESPONDENT (restrained person ), M F ) Birthdate ) Respondent is a child. Who is signing for the child? ) Name: Birthdate: ) CHILD SUPPORT INFORMATION Relationship to child: ) ) INSTRUCTIONS. If child support is requested in a petition for a long-term domestic violence protective order, each party must complete one of these information sheets and bring it to the court hearing on the protective order or file it with the court before that hearing. If you need help filling out the form, a court clerk can help you. Provide information about yourself and, to the extent it is available, about the other party. A court clerk can notarize this document for you at no charge. The information in this form is required by Civil Rule 90.3 and the statutes listed at the bottom of this form. If you want a copy of Civil Rule 90.3, ask the clerk for a copy of the booklet about child support, DR-310. The rule is in the back of the booklet. Each party must attach a copy of his or her most recent federal tax return and most recent pay stubs to verify income and deductions. AFFIDAVIT I swear or affirm under penalty of perjury that the following information is true t o the best of my knowledge and belief. I. Other Child Support Orders There are no other child support orders currently in effect concerning the children involved in this case. The following child support order(s) concerning these children are still in effect: Case No.: Effective Date: Page 2 of 4 Civil Rule 90.3 DV-101 (4/18)(cs) AS 25.27.062(a) CHILD SUPPORT INFORMATION AS 25.27.060(c) II. Income Information. The following income and deductions are monthly yearly. [Note: you must check either monthly or yearly for the math on this form to work .] I have attached a copy of my most recent federal tax return and pay stubs to verify this information. [Note: Delete social security numbers and account numbers from any documents you attach.] PETITIONER RESPONDENT A. Gross Income (Do not list ATAP or SSI below.) Gross wages Value of employer-provided housing/food/etc. Unemployment compensation Permanent fund dividend (PFD) Other: TOTAL INCOME B. Deductions Allowable Under Civil Rule 90.3 Fe deral, state and local income tax Social security tax or self-employment tax Medicare tax Employment security tax Mandatory retirement contributions Mandatory union dues Voluntary retirement contributions if plan earnings are tax-free or deferred, up to 7.5% of gross wages and self-employment income when combined with mandatory contributions Other mandatory deductions (specify): Alimony ordered in other cases & currently paid Child support ordered for prior children 1 In -kind support for prior children 2 Work-related child care for children in this case Health insurance for parent (up to 10% of wages) TOTAL DEDUCTIONS C. Net Income TOTAL INCOME from section A TOTAL DEDUCTIONS from section B Subtract deductions from income to get NET INCOME D. Adjusted Annual Income 1. If the above figures are based on monthly information, multiply NET INCOME from section C by 12 to get ADJUSTED ANNUAL INCOME 2. If the above figures are based on yearly information, repeat the NET INCOME amount from section C to show ADJUSTED ANNUAL INCOME 1 “Prior children” include children from a different relationship born or adopted before the children in this case. 2 For more information, see the Prior Child Deduction Chart and Civil Rule 90.3(a)(1)(D). Page 3 of 4 Civil Rule 90.3 DV-101 (4/18)(cs) AS 25.27.062(a) CHILD SUPPORT INFORMATION AS 25.27.060(c) III. Health Care Coverage for the Children. A. Health Insurance. 1. Does the petitioner have health insurance available for the child(ren) at reasonable cost through his/her employer, union, or otherwise? Yes No If yes, state name and address of employer, union or other source through which insurance is provided or available. Name: Address: Cost to petitioner: $ per month 2. Does the respondent have health insurance available for the child(ren) at reasonable cost through his/her employer, union or otherwise? Yes No If yes, state name and address of employer, union or other source through which insurance is provided or available. Name: Address: Cost to respondent: $ per month 3. Are the children eligible for services through the Indian Health Service? Yes No 4. Do the children have other health insurance or care available? Yes No Describe: B. Children’s Health Care Expenses Not Covered By Insurance. Is there any reason why the court should not require the parties to share equally the cost of reasonable health care expenses not covered by insurance? IV. Travel Expenses. Travel expenses to exercise visitation should be allocated between the parties as follows: Page 4 of 4 Civil Rule 90.3 DV-101 (4/18)(cs) AS 25.27.062(a) CHILD SUPPORT INFORMATION AS 25.27.060(c) V. Immediate Income Withholding. The Alaska Statutes require that child support be withheld from the income of the person paying support and paid through the Child Support Services Division (CSSD) unless one of the following exceptions is approved by the court: We have made the following alternative arrangement (Note that if you receive ATAP, CS SD must agree to the arrangement): Also, the person paying support agrees to keep the other party (or CSSD if CSSD is enforcing the order) informed of his/her current employer and the availability of employment-related health insurance coverage for the child(ren) until the support order is satisfied. We believe there is good cause not to require immediate income withholding because it is not in the best interests of the child(ren) for the following reason: Also, the person paying support agrees to keep the other party (or CSSD if CSSD is enforcing the order) informed of his/her current employer and the avai lability of employment-related health insurance coverage for the child(ren) until the support order is satisfied. The person paying support currently receives social security or other disability compensation that includes regular payments to the child(ren) at least equal to the child support owed each month. Monthly payment to child(ren): $ Source of payment: Note: To the extent that these payments to the children do not satisfy the monthly amount owed, the court will order that the remaining amount due be withheld from income. VI. Assistance from CSSD. If you want the assistance of the Child Support Services Division (CS SD) to enforce the support order and keep records of the payments, you must apply for CS SD services. You can get an application from CSSD or you can fill out court form DR- 315 (available at the clerk’s office) and mail it to CS SD at 550 West 7th Ave., Suite 310 , Anchorage, AK 99501. Signature Type or Print Name Subscribed and sworn to or affirmed before me at , Alaska on . Date (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: