ORDER OF SUPPORT (CIVIL) |
Case No |
ARREARAGES:
[ ] No arrearages exist as of . . . . . . . . . . . . . . . . . .
[ ] $ . . . . . . . . . . . . . . . . . child support arrearage owed by Respondent. [ ] $ . . . . . . . . . . . . . . . . . spousal support arrearage owed by Respondent.
[ ] $ . . . . . . . . . . . . . . . . . unitary (child/spousal) support arrearage owed by Respondent.
[ ] $ |
total SUPPORT arrears owed by Respondent [ ] with interest included [ ] without interest included |
[] arrears include an assessment from the effective date of this order to the first payment due date.
[ ] This total includes TANF debt or other public funds paid prior to the effective date of this order of $ . . . . . . . . . . . . . . . . .
for . . . . . . . . . . . . months.
These arrearages are calculated as of the date of this Order including support owed for the current month. This amount does not include
payments made after ____/____/____, and respondent shall be credited for any payments made thereafter. Interest shall continue to accrue
on unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest.
PAYMENT:
Payment shall be made payable to:
[] Petitioner at the address shown in the beginning of the Order.
The parties shall give the court at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer.
[] Treasurer of Virginia and sent to Virginia Department of Social Services, Division of Child Support Enforcement, P.O. Box 570, Richmond, Virginia 23218-0570 unless otherwise instructed by that agency or this Court and shall contain the following:
1.Check or money order made payable to the Treasurer of Virginia.
2.Print on the check or money order:
Your name and social security number
Petitioner’s name as shown on the first page of this order
The DCSE ID No. shown on the first page of this order. If no such number is shown, use this Court’s name and case number as shown on the front page of this order until that number is sent to you; then start using the DCSE ID No.
The parties shall give to the Virginia Department of Social Services and the court, at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the Virginia Department of Social Services and the court informed of the name, address and telephone number of his/her current employer.
[] The parties shall also give each other at least 30 days written notice, in advance of any change of residential and, if different, mailing address and of any change in telephone number within 30 days after the change.
WARNING: Failure to pay in accordance with this order is a violation of this order and may be punished by a jail sentence or a fine or both. In addition, you may not receive credit for payments made contrary to the payment instructions provided in this order. Whenever income withholding is authorized, it is your responsibility to make the payment to DCSE until the income withholding becomes effective. You are responsible for keeping records of payments you make.
HEALTH CARE PROVISIONS:
[] Respondent [ ] Petitioner shall provide health care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents
[] Respondent [ ] Petitioner shall provide dental care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents
[] Respondent [ ] Petitioner presently has health care coverage and is ordered to maintain it or comparable coverage.
Health Insurance Company |
Policy name |
Name of Policy Holder |
Policy number |
In the event of any change in health insurance, the responsible party is required to notify the opposing party of the change. The responsible party shall inform the Virginia Department of Social Services, if support payments are ordered to be paid through the Virginia Department of Social Services, or the opposing party, if support payments are ordered to be paid directly to the opposing party, of any changes in the availability of the health care coverage for the minor child or children.
[] The Court finds that “health care coverage” as defined by the statute is not available at “reasonable cost” as defined by statute, and therefore, the Court does not order either the Respondent or the Petitioner to provide health care coverage.
[] Any reasonable and necessary unreimbursed medical and dental expenses for each child covered by this order shall be paid in the
following manner: . . . . . . . . . . . . . . % Respondent . . . . . . . . . . . . . % Petitioner.