DONALD R.

HOFFMAN (#07332) 112 West 7th Street - Garden Suite Topeka, Kansas 66603

Tel: (785) 233-5887

Fax: (785) 233-2173

Attorney for Petitioner

IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 2

In the Matter of the Marriage of

HAL RICHARDSON and

CLAUDINE DOMBROWSKI

Case No. 96 D 217

AGREED ORDER

NOW on this 2. J day of Prwrr, 2001, comes on for approval of the Court, the within agreement of the parties regarding child support. Petitioner appears through counsel, Donald R. Hoffman. Respondent appears through counsel, Leonard M. Robinson.

The Court after reviewing the file and being fully advised, finds:

1. Respondent shall pay Petitioner $225.00 per month child support commencing

August 1, 2001.

2. Petitioner shall continue to maintain the present health insurance All unreimbursed

medical expenses for the parties' minor child shall be paid proportionately by the parties in accordance with their respective incomes as set forth in the child support worksheet "A", Petitioner

28.511. % and Respondent 71.4%%. (See attachment).

3 . Petitioner is entitled to the tax exemption for the minor child, Rikki A. Dombrowski,

DOB: 12-12-94, for the year 2001 and the years thereafter.

4. The attached mandatory supplemental orders required by Shawnee County District

Court Rule 3.401 are hereby incorporated herein by reference.

5. That all prior orders not modified herein shall remain in full force and effect until

further order of this Court.

"

IT IS SO ORDERED.

. (

H AN & HOFFMAN

112 West 7th Street -Garden Suite Topeka,Kansas 66603

Tel: (785) 233-5887

Fax: (785) 233-2173

Attorney for Petitioner

~-

LEONARD M. ROBINSON 201 N.W. Hwy 24, Ste. 140 P.O. Box 8138

Topeka, Kansas 66608-0138 (785) 233-7001

Attorney for Respondent

2

___ fiM_Jd_4b __

DISTRICT COURT JUDGE

MANDATORY SUPPLEMENTAL ORDERS

The following mandatory supplemental orders pertaining to enforcement of child support are incorporated in the foregoing order and are incorporated as a part thereof pursuant of Shawnee County District Court Rule #3.401:

IT IS FURTHER ORDERED that all child support payments shall be paid to the Kansas Payment Center, P.O. Box 758599, Topeka, Kansas 66675-8599 unless otherwise ordered by the Court. Any payments of child support not made in accordance with this provision shall be presumptively disallowed. Any payments made payable to the obligee may be endorsed and cashed by the Kansas Payment Center.

IT IS FURTHER ORDERED that all new or modified non-N-D support orders must be accompanied by a support order information sheet available in the office of the clerk of the District Court.

IT IS FURTHER ORDERED that the Office of SRS or their contracting agent for IVD cases, or the District Court Trustee for private cases shall monitor and enforce the payments of support ordered herein and may pursue on behalf of any child all civil remedies available to the obligee to enforce payments of child support.

IT IS FURTHER ORDERED that each party shall inform the Clerk of the District Court, the Kansas Payment Center and SRS for IV-D cases, or the District Court Trustee for private cases in writing of any changes of name, residence, and employer including business address within seven (7) days after such change.

IT IS FURTHER ORDERED that withholding of income to enforce this order of support or modification shall take effect thereto without further notice pursuant to K.S.A. 23-4, 107, and any amendments thereto.

IT IS FURTHER ORDERED that the amount of child support payable per month in this case is $225.00 current, commencing August 1, 2001, and due on or before the 1st day of each month. The payments in this case are to be paid monthly.

IT IS FURTHER ORDERED that the following information be provided each time an Order is entered:

Petitioner Respondent
Home Phone: Home Phone:
(785) 379-5254 (785) 539 .. 5583
Home Address: Home Address:
1727 Shawnee Heights Rd. PO Box 984
Topeka, Ks 66542 Manhattan, KS 66505
Employer Name: Employer Name:
Topeka Vinyl Top Center Not employed
Business Phone: Business Phone:
(785) 266-4114 N/A
Soc. Sec. No.: Soc. Sec. No.:
510-70-4518 511-74-9645 07/24/2001 14:37

785-233-7051

DAVID MILLER OR LMR

IN THP: DISTRICT COURT OF SHAWNEE COUNTY, KANSAS Division

In the Matter of the Marriage of

HAL RICHARDSON and

CLAUDINE DOMBROWSKI

CHILD SUPPORT WORKSHEET (SUBMITTED av MOTHER)

GROSS ANNUAL INCOMES:

A. INCOME COMPUTATION - WAGE EARNER

1, Domestic Gross Income (Wages, il1terest, etc.)

B INCOME COMPUTATION - SELF-EMPLOYED

1 Self-Employment Gross Income

2 Reasonable Business Expenses (Incl. SE tax)

3. Domestic Gross Income (Self-Employed)

C ADJUSTMENTS TO DOMESTIC GRQSS INCOME

1, Gross Income (Total-Monthly)

Cost of living Adjustment

2 Other Court~Ordered ChUd Support Paid 3, Maintenance Rec'd (paid) In this case

4. Maintenance Rec'd (Paid) other cases

5. Child Support Income

D, COMPUTATION OF CHILD SUPPORT

1. Child Svpport Income

2. Proportionate Shares of Combined Income

3. Basic Child Support Obligation

Case No. Division

MOTHER 10,692

FATHER 26,628

Age of children Number per age Amount per child

c

891

2,2.19

1 375

o o

o

PAGE 02

Copy

96-D-217 2

TOTAL 37,320

3,110

o o

o

o

TOTALS

375

691 2,219
0 0
0 0
0 0
0 0
891 2,219 3,110 891 28.6%

2,219 71.4%

.7-151

o o

o

3.110 100.0%

o o

o

375

07/24/2001 14:37

785-233-7051

Page 2

D. COMPUTATION OF CHILD SUPPORT (Cont.)

4. Health and Dental Insurance Premium

5. Work-Related Child Cere Costs

Less Child Care Tax Credit (Incl. Kansas credit)

6. Parents' Tctal Child Support Obligation

7. Each Parent's Child Support Obligation

6. Adjustment for Insurance & Child Care

9 Net Parental Child Support Obligation (Percentage of Parent's Gross Income)

E, CHILD SUPPORT ADJUSTMENTS

Applicable

Yes No

1, X

2, 3. 4. 5. 6,

category

Long Dist. Vi$itation Costs Visitation Adjustment Income Tax Considerations SpeCial Needs

Agreement Past Minority Overall Financial Condition

7. Total Adjustments

F ADJUSTED CHILD SUPPORT SUMMARY (Deviations from rebuttable presumption amount)

1 Basic Parental Child Support Obligation 2, Total Child Support Adjustments

3. Adjusted Subtotal

Child Support Payabr. by Mother

Child Support Enforcement Fee Anowance Total Amount Payable

Prepared by

Leonard M, Robinson # PO Box 8138

Topeka. KS 66608-0138 785233·700.1

Attorney for Respondent

Administrative Order No 128

Signed:

Date:

DAVID MILLER OR LMR

PAGE 03

(

Case No, 96-0-;(17
MOTHER FATHER TOTAL
0 81 81
0 433 433
0 (53) (53)
0 461 461
836
239 597
0 (461) (461)
239 136 375
26.8% 26.9% Amount Allowed
Mother I Father
0 0
0 0
(24) 24
0 0
0 0
0 0
(24) 24 o

MOTHER

FATHER

239 (24)

136 24

215

160

375

215 2

217

Prepared:

3/8(01

KS2000 VerSion 12.1 Copyright 2000 Bradley Software

Kansas Payment Center -- Child Support Order Information Sheet

J.:.umose: Federal law requires Kansas to process child support through a single location in the slate. To insure that processing of child support payments is not delayed, the Kansas Payment Center must have all information listed on the form below.

Who submits the completed form: The payee's attorney shall file the completed form along with the Journal Entry with the Clerk of the District Court per Kansas Supreme Court Administrative Order No, 154.

Case Number: You must give the full, accurate court order number, or payments may be delayed. The case number may be copied from the child support order. The case number format is as follows:

County - Year - Case Type - Case Number

Example: WYOOD 000123 (WY) (00) (D) (000123)

Please call your local clerk of the district court if you need additional information to complete this form.

Additional copies may be made as necessary.

PLEASE print or type all information.
Case Number: SN 96 D 217 Check if applicable: Check one:
o New case/order
Circle One o Court Trustee case .fJ Modified order
Interstate: Y @ Filcsramp Date of Or del' (above):
. -~ .. - ... -
Obligation Information Support Frequency Start Payment frequency Codes
Amount Code Dale (W) Weekly
(B) Biweekly
Current Child Support due: $225.00 s 225.00 hi 8-3-01 (M) Monthly
(SM) Semi-Monthly
Current Maintenance (Alimony) due: s _. (Q) Quarterly
...
... (A) Annually
Other Support due: $ (SA) Semi-Annually
(L) Lum~um ~~.."
s 0;:0'-
~ -,oS~
o<-~a
$ Ci"' ~~~~
,
cr 'JIP~-'C'"
s - '?~
~r-
~ <!'dC::~
s ~~
ctJ r'"
....,
0 -,
Information about the PAYING Parent
,
NIu'vfE (First, Middle Initial, Last):
CLAUDINE DOMBROWSKI
Social Security Number: Date of Birth: Phone: , ,
511-74-9645 04/10/65 785 539-5583
-
Address: City: Slate: Zip:
PO Box 984 Manhattan KS 66505 9/1'4/00

Information about the Parent or Person RECEIVING support
~--
NAME (First, Middle Initial, Last);
HAL RICHARDSON
Social Security Number: Date ofnirth: Phone:
510-70-4518 9-9-60 266-4114
Address: City: State: Zip:
1727 SHAWNEE HEIGHTS RD. TECUMSEH KANSAS 66542
Information about the Third Party Payee
NAME (first, Middle Initial, Last) N/A
Social Security Number: Date of Birth: Phone:
Address: City: State: Zip:
Information about CIDLD(REN) covered by this support order
N/\Ml~ (First and Last): Social Security Number: Date of Birth:
1. RIKKI 513-11-4344 1'-12-94
2.
3. \
...
4. ...
5.
6.
7.
S.
9. form Completed By: _

. ~ Dale: ._---

Print Name (and title):

DONALD R. HQFFMAN ... ~(~#~Ou7~3~3~24) .~ _

Attorney for Petitioner

The completed form must be attached to the journal entry and filed with the Clerk of the District Court.

J •

09/14/00

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