WPC Эesh| S~/*i99ئjZgvɬ2|?uf^\)*t2Qɴ10U-Lb)l5'%wqo*0@ƀ>ܮ$9$ݙ\߂E*&9.$}5wom&mאK \UaU(7/ƀ# (o*%I{4#`u5Ie#G;1SWFý/)gZ)l# dUjNo % 0|UcN?w@4fa  0& h  0JJJJJJJJJJJJJJJJJJJJ 0 B zzzzz A B * C @@@@@@@@ D3ZSPOT 4SiHPPCL5MS,,,,,,0vLl(hH  Z 6Times New Roman RegularX(T:$TRY 3'StandardY 3'Standard 3' Letter 3' LetterT(9 Z 6Times New Roman Regular DDDQDDUk&3|xTABLE A (|3Pc$ :!TRX3'Standard3'3'Standard3'T   d  +  ?  ?  ? @  ? @ @  @  @  @ @ @  D@   D@  @  "@ D@ $@ $@   &@ D@   D@ D@   D@ TABLE A  x f)  XX`"`"A4&(Revised7/1/99)(p3f$ :!TRX3'Standard3'3'Standard3'T  (p3f$ :!TRX3'Standard3'3'Standard3'T   d%y  <<= 8C&0 d d d0000'dxd :!TRX3'Standard3'3'Standard3'T  ,, X"XXX7dd7 7+'XXX'@   q XX"MONTANASTATECASEREGISTRY , @ANDVITALSTATISTICSREPORTINGFORM # q   q#Ԉ `4 @ DEPARTMENTOFPUBLICHEALTHANDHUMANSERVICES#X"X  q_#Ԉ h   (Seeinstructionsonotherside) &&XX"  *w =' ddd Xdd Xdd X4&4&w,dd!,dd!,Vd!+  .5  .<T(?" ,X<pxk(XXX?County/Tribe__________________________________JudicialDistrictNo._______CauseNo._______________ @5+"T(5 @N" ,X<pX(X ,X<pxk(XNT(DateDecree/OrderSigned________________________________0  DissolutionofMarriageA 0  CountythatIssuedMarriageLicense___________________  N" , X<pX(X ,X<pX(XN0  City,County,StateofMarriage________________________&&&&   0  DateofMarriage___________________________________  0  0WithChildSupportOrder  Ѐ0  WithoutChildSupportOrder(CompleteParts1,2&9only)  #&&&&#&&&&ModificationofChildSupportOrder#&&&& # 35 5 3&&&&0 \ ChildSupportOrder,withoutDissolution(Includes  TemporarySupportOrdersandPaternityOrderswithChildSupport)#&&&&" #&&&& n\%\% LegalSeparationwithChildSupportOrder#&&&& #&&&&  [  DependentNeglect/JuvenileDelinquency t H  InvalidMarriageSpecifyLegalGroundsforAction a 5  ______________________________________________________________________________________#&&&& # E;; 5  ?1?EЀ1 T5?9{  ?1 ? T ffZ.AX X a"X , X<pX(XZMother/Wife: 󀀀0  PayerPayeeBothN/A0%%MaidenName:_________________________________{%% rffName:_____________________________________________SSN:_______________&&&&Telephone:P P @%(____)__________ r #&&&&#  r &&Last#&& r#r &&  0  0  % %First0Q % %0Q%Q%Middle/Suffix#&& r# 3)#vJ%%5 3  > l4AX  a"XAX X a"Xl&&&&f:vMailingAddress:XX%__________________________________________________________________________________ f: r &&    0  Street     0%%0%%0%%City  0a%%  0"a%a%State0i$"%"%Zip>i$%i$% #&& r#ffResidentialAddress(ifdifferentfromabove):@@%____________________________________________________________  l.AX X a "XAX  a"XlffDateofBirth:___________________________PlaceofBirth:0  _____________________________Race:""G%%%_________#&&&&E#&&&&Ԉ      r &&0  0 %%0  % %0Q % %0Q%Q%0%%0%%0%%State/ForeignCountry#&& ru##&&&&(#&&&&%% #&&&&#i1AX Xp a "XAX X a "XiffDriversLicense#/State_____________________________0  &&&&Occupation:___________________________________tH%% #&&&&#&&&&Numberofthismarriage(1st,2nd,etc.):_____#&&&&?#ԀDate,City&Stateofpreviousmarriage(s):008%________________________ H>v   @2@HЀ2 T5?9!  @2 @ T Father/Husband:   0  PayerPayeeBothN/A" % % AffName:_____________________________________________SSN:_______________&&&&Telephone:P P @%(____)__________#&&&&#Ԉ # f  r &&Last0  0 %%0  % %First Q 0 % %Middle/Suffix#&& r># 3)#$%%5 3  y$ o4AX QXp a "XAX Xp a "Xo&&&& fMailingAddress:XX%__________________________________________________________________________________ % r &&ff    0  Street    Q 0%%0%%0p%%0p%p%City  0a%% 0"a%a%State0i$"%"%Zipy&i$%i$% #&& r#ResidentialAddress(ifdifferentfromabove):@@%____________________________________________________________ yM' ff{=AX QXD a "X')XAX QXp a "X{DateofBirth:___________________________PlaceofBirth:0 D _____________________________Race:""H%D%D%________#&&&&#&&&&Ԉ {(     r &&0  0 %%0  % %0 % %0Q%%0Q%Q%0%%0D%%0D%D%State/ForeignCountry#&& r!##&&&& #&&&&S)%% #&&&&?"#=AX QXD k "X')XAX QXD a "X')XffDriversLicense#/State_____________________________&&&&0 D Occupation:__________________________________ *D%D% #&&&&r##&&&&Numberofthismarriage(1st,2nd,etc.):_____#&&&&$#ԀDate,City&Stateofpreviousmarriage(s):008%________________________ 0'E! + 0i" ,`Ubh X XAX QXD k "X')XiӀ OtherPayee: Ifsupportistobepaidtoanotherpayee,checkhereandcompletePart4. K0:"!,'  @3@KЀ3 L0;5!$"-  @3 @0 L && ff3! ,`Ubh X X3NamesofChildrenIncludedintheSupportOrder 0 ! Residing!$".!%!% ff0 AQk!(#i$X!0ӀLast󀀀First󀀀Middle  DateofBirth Q Sex k SSN0 ! With**$#/!%!% H A^!(#i$X AQk!(#i$XH__________________________________________________________0  MF0^%%___________________0!^%^%MFBO%$0!%!%   _________________________________________0  _________________0%%MF0^%%___________________0!^%^%MFBO '%1!%!% #&& o&##&&&&?)#&&&& &&_________________________________________0  _________________0%%MF0^%%___________________0!^%^%MFBO(&2!%!% #&& *##&&&&j*#&&&& &&_________________________________________0  _________________0%%MF0^%%___________________0!^%^%MFBO1)(3!%!% #&& +##&&&&+#&&&& &&_________________________________________0  _________________0%%MF0^%%___________________0!^%^%MFBOC*)4!%!% #&& -##&&&&,#&&&& &&_________________________________________0  _________________0%%MF0^%%___________________0!^%^%MFBOU+)*5!%!% #&& g.##&&&&H.#&&&&ffH A!(#i$X A^!(#i$XH0  0%%0%%0%%0!%%r &&**M=MotherF=Father#&& rg0# &&g,;+6!%!% #&& 0#Ifanyoftheabovenamedchildrenarenotresidingwithaparent,listthechildsnameandaddress:0 ! r &&B=BothO=Other#&& r1#Ԁ,+7!%!%  &&%________________________________________________________________________________________________________ C.-9 #&&  2# &&#  /#   @ ________________________________________________________________________________________________________#  43##&& 2# D:i/=.;0  @4@D 7+  K" ,`Ubh X X A!(#i$XKӀ4 8.(d  @4 @ 8 OtherPayee:  d Nameofperson/agencyowedsupportifnotparent:<<%______________________________________________________ h< r &&  0  0%%0 %%0Q % %0Q%Q%LastNameorAgencyName0%%0 %%0a % %First0a%a%0"%%Middle@"%"% r  r#&& r5#MailingAddress:_________________________________________________________Telephone:P P @%(____)__________r &&Ԉ $     0  Street  Q 0%%City   Y State    Zip%% #&& r7#ResidentialAddress(ifdifferentfromabove):%___________________________________________________________#&&&&7#Ԉ :0    @5@:Ѐ5 H>5L    @5 @ H@ ProtectiveOrder: Isapartytothisactionprotectedfromanotherpartytotheactionbyanorderofprotection?YesNo L   Ifyes,entername(s)ofprotectedparty(ies):%_____________________________________________________________ J'=_3   @6@JМ6 K'>5    @6 @' K 33@Employer/IncomeSourceInformation: Provideinformationaboutthepayersemploymentorperiodicsourceofincome.   (Attachadditionalpagesifneeded.)񀀀0 Q 񀀀CheckhereifthisorderrequiresbothpartiestopaysupportandskipParts6&7.andcCompleteParts8,9,10&11.   %_______________________________________________________________________________________________r &&33NameofEmployerorSourceofIncome0 0Q % %0Q%Q%0%%0Y%%0Y%Y%0 %%0a % %0a%a%Telephone#&& rp># %% ________________________________________________________________________________________________r &&Street0  0%%0%%0 %%0Q % %0Q%Q%City0%%0Y%%0Y%Y%0 %%State0a % %0"a%a%Zip&& rԛ U'H#"%"%'  @7@UМ7 d'5OF"II  @7 @' d&&&& SupportOrder: 󀀀DateOrderSigned:_________________#&&&&=B# ,''5 , ,"' ,Y-Checktypeofsupportandenterappropriateinformation%&&&&Ifapplicable,arrearsdueattimeoforder:$____________#&&&&C#Ԉ ,' , ,"' , i=U,U` eD}(#&(X ,`Ubh X XiY-ԀSupportType0  0 %%TotalDue0 % %0 % %Frequency0%%0%%BeginDate0%%EndDate0%%Judgment0%%Penalty*0%%Fees*0l#%%Interest*l#%l#% 0  0%%0%%0 %%0 % %0 % %0%%0%%0%%0%%0 %%0 % %r &&Ԁ(*listamountsifincludedinjudgment) #&& r'G# 6')#%% 6 75"a' 7 && ChildSupport: 0  0 %%$__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______#&& H# 6')#l#%l#%5 6 ,"' , && MedicalSupport: 0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______M!l#%l#%  SpousalSupport:0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______ yMl#%l#% Ѐ(Alimony) 0  0 %%@A % % #&& I#IspayerexemptfromincomewithholdingunderMCA405315?NoYesTribalOrder 6   Listanyspecialterms/conditionsofthesupportorder(s):44%_________________________________________________ D! %_______________________________________________________________________________________________Wasthemotherrepresentedbyanattorney?YesNoWasthefatherrepresentedbyanattorney?YesNo&&&& `4# f pD ;')XU,U` eD}(#&(Xf@  Informationfromchildsupportguidelinesworksheet:  nB$ #&&&&N#&&&& 0  Mother:0%% IncomeafterDeductions:0%%$_________0D%% CreditforPaymentofExpenses:0 D%D%$_________#&&&&O#&&&&|P% % % 0  Father: 0%%#&&&&P#&&&& IncomeafterDeductions:0%%$_________0D%%#&&&&R# ND#c& % %   @8 @NЀ8 8.( '   @8  @ 8 &&&&lCp  f!;')X pD ;')XlHealthInsurance: 󀀀#&&&&)S#(Attachadditionalpagesifneeded.)&&&&Ԁ  ( Ishealthinsuranceprovidedforthechildren?#&&&&T#YesNo&&&&Ԁ(Ifno,answerlastquestioninthissection) " ) #&&&&T#&&&&Nameandrelationshipofpartyprovidinginsurance:________________________________PolicyNo._____________#&&&&4U#&&&&  #!* Nameofinsurancecarrierorhealthbenefitplan:TT%_________________________________________________________ .$#+ Addressofinsurancecarrierorhealthbenefitplan:_________________________________________________________#&&&&U#&&&& <%$, Namesofchildrencovered:8 8 %__________________________________________________________________________ J&%- Terms/conditionsofcoverage:L L %_______________________________________________________________________ X',&. Ifchildrenarenotcovered,iscoverageavailablethrough:0  Fathersemployer?0 %%YesNo0 % %0%%0%%Mothersemployer?YesNo#&&&&=W#ԛ H07t)H(0%%  "@9"@HМ9 P05;5*)1  "@9 "@0 P Thisformwascompletedby: 󀀀Name/Title:%__________________________________________________________ *)2 Cp  l#;')Xp  f!;')X@Telephone:________________Signature:__________________________________Date:_____________________   Completenextpageifbothpartiesareorderedtopaychildsupport. [  Informationcontainedinthisformisprivateandconfidential. {.O-6 ЀItmayonlybesharedwithcourts,agenciesandindividualsauthorizedbyMCA405923. 50("S/'.7!05 5A\&& ldMultiplePayers:CompleteParts10and11onlyiftheorderrequiresbothpartiestopaysupport. #&&?]#lh< H>h<0  $@10$@H10 F<6  $@10 $@ F MothersEmployer/IncomeSourceInformation: Provideinformationaboutthemothersemploymentorperiodicsource  ofincome.(Attachadditionalpagesifneeded.)<%_______________________________________________________________________________________________r &&NameofEmployerorSourceofIncome0 0 % %0 % %0%%0%%0%%0%%0%%0 %%0 % %0%%Telephone#&& r_#%% %_______________________________________________________________________________________________r &&Street0  0%%0%%0 %%0 % %0 % %0 % %0%%0%%0%%City0%%0%%0 %%0 % %0%%State0l#%%0@l$%%Zip#&& ra# "T l#%l#% "      FathersEmployer/IncomeSourceInformation: Provideinformationaboutthefathersemploymentorperiodicsource    ofincome.(Attachadditionalpagesifneeded.)< p ` 4 %_______________________________________________________________________________________________r &&NameofEmployerorSourceofIncome0 0 % %0 % %0%%0%%0%%0%%0%%0 %%0 % %0%%Telephone#&& r(e#t H %% %_______________________________________________________________________________________________r &&Street0  0%%0%%0 %%0 % %0 % %0 % %0%%0%%0%%City0%%0%%0 %%0 % %0%%State0l#%%0@l$%%Zip#&& r!g# I?0 l#%l#%  &@11&@I11 e5PG\0#II  &@11 &@ e&&&& SupportOrder: 󀀀DateOrderSigned:_________________#&&&&~i# ,"\05 , )h< )&&&& MothersSupportObligation 0 0 % %0%%0%%#&&&&bj#&&&&ԀIfapplicable,arrearsdueattimeoforder:$_______#&&&&"k#%% &&&&Checktypeofsupportandenterappropriateinformation#&&&&k#    ," ,&&&& =U,U` eD}(#&(Xp  l#;')XӀSupportType0  0 %%TotalDue0 % %0 % %Frequency0%%0%%BeginDate0%%EndDate0%%Judgment0%%Penalty*0%%Fees*0l#%%Interest* #&&&&l#Vl#%l#%  &&&&0  0%%0%%0 %%0 % %0 % %0%%0%%0%%0%%0 %%0 % %r &&(*listamountsifincludedinjudgment) #r  rn##&& ro# 6,#Z.%% 6 75"" 7 &&&& &&<Z@ChildSupport: 0  0 %%$__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______#&& p##&&&&p# 6,#l#%l#%5 6 ," ,&&&& &&<Z. Z.MedicalSupport: 0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______l#%l#%  @SpousalSupport:0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______#&& r# && l#%l#% Ѐ(Alimony)   #&& hu# &&IsthemotherexemptfromincomewithholdingunderMCA405315?NoYesTribalOrder#  r##&& u# )8  ) -#dzz' - FathersSupportObligation 0 0 % %0%%0%%0%%&&&&Ifapplicable,arrearsdueattimeoforder:$________#&&&&w#d %% Checktypeofsupportandenterappropriateinformation  " ӀSupportType0  0 %%TotalDue0 % %0 % %Frequency0%%0%%BeginDate0%%EndDate0%%Judgment0%%Penalty*0%%Fees*0l#%%Interest*$l#%l#% @0  0%%0%%0 %%0 % %0 % %0%%0%%0%%0%%0 %%0 % %r &&(*listamountsifincludedinjudgment) #&& rz# 3)#%%% 3 *5 % *  &&<^ 2" ChildSupport: 0  0 %%$__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______#&& {# 3)#^ 2&l#%l#%5 3  V!* &  &&<! !  !^ ! MedicalSupport: 0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______!^ 'l#%l#%  @SpousalSupport:0 $__________per__________0 % %________0%%________0%%$_______0%%$______0%%$_______0l#%%$______#&& e}# && "X!(l#%l#% Ѐ(Alimony) 0  0 %%L# ") % % #&& # &&#&& # &&IsthefatherexemptfromincomewithholdingunderMCA405315?NoYesTribalOrder#&& ΀#ԛ  $#+  &,&%, &М33Listanyspecialterms/conditionsofthesupportorder(s):44%_________________________________________________ ,&%- %_______________________________________________________________________________________________̜33__________________________________________________________________________________________________Wasthemotherrepresentedbyanattorney?YesNoWasthefatherrepresentedbyanattorney?YesNo v)J(1 @f pD ;')XU,U` eD}(#&(Xf&&&&@  Informationfromchildsupportguidelinesworksheet:  *)3 #&&&&z#&&&& 0  Mother:0%% IncomeafterDeductions:0%%$_________0D%% CreditforPaymentofExpenses:0 D%D%$_________#&&&&#&&&&+*4 % % 0  Father: 0%%#&&&&$#&&&& IncomeafterDeductions:0%%$_________0D%%#&&&&#&&&& CreditforPaymentofExpenses:#&&&&K#&&&&0 D%D%$_________#&&&&#lCU,U` eD}(#&(X pD ;')Xl,+5 % % -,6      .-6 @   &&&& Y<&&INSTRUCTIONS#&&Y<]# X"X&& H /  #X"XXX";#X"XXX" OrderInformation: Checktheboxthatmostaccuratelydescribesthetypeoforderbeingentered. yM Ifitisadissolutionofmarriage,entertheplaceofmarriageandindicateifchildsupportisordered.Temporarysupportordersandpaternityordersthatcontainchildsupportarecategorizedas childsupportorder,withoutdissolution. Childsupportorderincludesmedicalsupportorders.Iftheorderdoesnotcontainachildsupportorder,socialsecuritynumbersofthepartiesarenotrequiredandonlyParts1,2and9needtobecompleted. Parts1and2: Provideinformationaboutthepartiestotheorder.Ifthereisachildsupportorder, { O  besuretochecktheboxthatshowswhetherthepartyowessupport(payer)orwillreceivesupport(payee).Ifapartyisorderedtobothpayandreceivesupport,checktheboxlabeled both.Ifthereisnosupportorder,checktheboxlabeled N/Afornotapplicable.Ifapartyisorderedtopay$0support,thatpartyshouldbeconsideredapayer. Part3: Provideinformationaboutthechildrennamedintheorderandindicatewhichparentorother e partythechildrenlivewith.Iftheparentingplanprovidesforsharedresidentialparenting,circle Bforboth.Ifachildisnotlivingwitheitherparent,circle Oandlistthechildsnameandaddress. Part4: Completethispartifsupportisorderedtobepaidtoanagencyoranindividualotherthan  aparent. Part5: Indicatewhetheranyofthepartiesareprotectedfromeachotherbyaprotectiveor ! restrainingorder.Ifyes,listthenamesoftheprotectedparties.Thisincludesanyprotectedchildren. Part6: Provideinformationabouttheemploymentorothersourceofincomeofthepartywhois sG orderedtopaychildsupport.Ifbothpartiesareorderedtopaysupport,skipPart6andcompletePart10instead. Part7: Provideinformationaboutthesupportorder.Checkthetype(s)ofsupportorderedand   entertheamountandhowoftenitisdue.(Example:$100perweek.)Allordersshouldhavea begindate;manywillnothavean enddate.Ifbothpartiesareorderedtopaysupport,skipPart7andcompletePart11instead.c,XF` XU,U` eD}(#&(XcIftheorderentersajudgmentforpastduesupport,showthe total amountofthejudgment.Ifthe % judgmentincludesamountsforpenalties,feesorinterest,listthoseamountsontheappropriatelines.Listanyspecialconditionsofthesupportorder.(Example:supportisdueuntilthechildgraduatesfromcollege.)Copytheinformationrequestedabouttheguidelinestothisformfromtheguidelinesworksheet. Part8: Provideinformationabouthealthinsurancecoverageforthechildren.Ifinsuranceisnot f%:$- provided,indicatewhetheritisavailablethroughtheemployerofeitherparent.Relationshipofthepartyprovidinginsuranceisthepartysrelationshiptothechildren.(Example:mother,father,mothersspouse,fathersspouse.)Listthetermsandconditionsoftheinsurancecoverage.(Example:80/20plan,$500deductible,majormedicalonly.) Part9: Provideinformationaboutthepersoncompletingthisform. |*P)3  Part10: Employmentinformationformultiplepayers.Completeonlyifbothpartiesareorderedto +*5 paysupport.SeePart6instructions. Part11: Orderinformationformultiplepayers.#X"XXX"##X"XXX"Completeonlyifbothpartiesareorderedtopay 3.-8 support.SeePart7instructions.#X"XXX"u# h