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Uniform Support Order

Uniform Support Order

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Published by Chris Buck

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Published by: Chris Buck on Jul 30, 2012
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11/28/2012

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NHJB-2066-FS (01/01/2011) Page 1 of 6
THE STATE OF NEW HAMPSHIRE
 
JUDICIAL BRANCH
http://www.courts.state.nh.us
 
Court Name:
 
Case Name:Case Number:
UNIFORM SUPPORT ORDER
Name, Residence and Mailing Address of Person Name, Residence and Mailing Address ofOrdered to Pay Support (Obligor) Person Receiving Support (Obligee)D.O.B. Telephone D.O.B. TelephoneE-mail Address E-mail AddressName of Employer: Name of Employer:Address of Employer: Address of Employer:Child(ren) to whom this order applies:
Full Name Date of Birth Full Name Date of Birth
The following parties appeared: Obligor Obligee Division of Child Support ServicesOtherNOTE: SECTIONS PRECEDED BY ARE ONLY PART OF THIS ORDER IF MARKED.1. This order is entered: 2. This order is a:after hearing temporary orderupon approval of agreement final orderupon default3. This order modifies a final support obligation in accordance with:a three-year review (RSA 458-C:7) OR substantial change in circumstances, asfollows:4. Obligor is ORDERED to PAY THE FOLLOWING AMOUNTS (See Standing Orders 4A-4G):4.1 CHILD SUPPORT: $ per
(week, month, etc.)
 4.2 Arrearage of $ as of ,payable $ per
(week, month, etc.)
 
Clear Form
 
Top of Page
 
Case Name:Case Number:UNIFORM SUPPORT ORDER
NHJB-2066-FS (01/01/2011) Page 2 of 6
4.3 Medical arrearage of $ as of ,payable $ per
(week, month, etc.)
 4.4 SPOUSAL SUPPORT (ALIMONY): $ per
(week, month, etc.)
 4.5 Arrearage of $ as of ,payable $ per
(week, month, etc.)
 4.6 Alimony shall terminate5. Payments on all ordered amounts shall begin on . All ordered amountsshall be payable to Obligee Division of Child Support Services Other6. This order complies with the child support guidelines. RSA 458-C.This order, entered upon obligor’s default, is based on a reasonable estimate of obligor’sincome. Compliance with the guidelines cannot be determined.The following special circumstances warrant an adjustment from the guidelines (Enterapplicable circumstances below. See Standing Order 6):7. Support ordered is payable by immediate income assignment.8. The Court finds that there is good cause to suspend the immediate income assignmentbecause:Obligor and obligee have agreed in writing.Payments have been timely and it would be in the best interest of the minor child(ren)because:9
A
. Obligor is unemployed and
MUST REPORT EFFORTS TO SEEK EMPLOYMENT.(See Standing Order 9A).
9
B.
Upon employment the Obligor shall bring the matter forward for recalculation of support.Failure to do so may result in a recalculated support order effective the date of employment.
 MEDICAL SUPPORT FINDINGS (Paragraphs 10 through 15)
 10.
OBLIGOR’S
medical support
 
reasonable cost obligation: $ per
(week,month, etc.)
10
A
. The medical support reasonable cost obligation is adjusted from the presumptiveamount because of the following special circumstances (Enter applicable circumstancesbelow. See Standing Order 6):11. Private health insurance coverage is not available is available to the
OBLIGOR in anamount equal to or less than the amount of the medical support reasonable costobligation ordered in paragraph 10.
 12. Private health insurance coverage available to the
OBLIGOR
is not accessible to thechild(ren).13.
OBLIGEE’S
medical support reasonable cost obligation:$ per
(week,month, etc.)
Top of 1st Page
 
Case Name:Case Number:UNIFORM SUPPORT ORDER
NHJB-2066-FS (01/01/2011) Page 3 of 6
13
A
. The medical support reasonable cost obligation is adjusted from the presumptiveamount because of the following special circumstances (Enter applicable circumstancesbelow. See Standing Order 6):14. Private health insurance coverage is not available is available to the
OBLIGEE in anamount equal to or less than the amount of the medical support reasonable costobligation ordered in paragraph 13.
 15. Private health insurance coverage available to the
OBLIGEE
is not accessible to thechild(ren).
PRIVATE HEALTH INSURANCE COVERAGE(Paragraph 16
A
and/or 16
B
must be completed):
 16
A
. Obligor Obligee is ordered to provide private health insurance coverage for thechild(ren) effective16
B
. Obligor Obligee is/are not ordered to provide private health insurance coverage at thistime but is/are ordered to immediately obtain private health insurance coverage when itbecomes accessible and available at an amount equal to or less than the ordered medicalsupport reasonable cost obligation.
UNINSURED MEDICAL EXPENSES
 17. Uninsured medical expenses shall be paid in the following percentage amounts:Obligor % Obligee % Other:18. Public assistance (TANF) or medical assistance (Medicaid) is or was provided for the children.Copies of pleadings related to medical coverage and child support were mailed to the Divisionof Child Support Services, Child Support Legal, 129 Pleasant Street, Concord, NH 03301.19. Obligor Obligee is adjudicated the father of the minor child(ren) named above. The clerkof the city(ies) of shall enter the name of the father onthe birth certificate(s) of the child(ren). The father’s date of birth is andhis state of birth is .20. The State of has provided public assistance for the benefitof the minor child(ren) between andfor weeks. Obligor is indebted for the assistance in the total amount of $21. Variation to standing order (specify paragraph #), additional agreement or order of the Court:
Obligor Obligee Staff AttorneyDivision of Child Support Services
 
Obligor’s Attorney/Witness Obligee’s Attorney/WitnessDate Date Date
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