Petition For Dissolution Of Marriage Page 10
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153. Monthly Child Support Payment (before calculating health insurance adjustment).
Child support will be paid as stated below. The first payment will be made no later than
st
. Subsequent payments will be made no later than the
1
day
of each month thereafter. (See definitions of types of custody in Civil Rule 90.3(f).)
a. Primary Custody. One parent has primary physical custody. Divide Annual Child
0
Support amount from line 2 above for the non-custodial parent by 12 = $
to be paid each month by
mother
father.
b. Shared Custody. The children will reside with each parent for a period specified in
writing of at least 30% of the year. [Attach form DR-306 to show calculations.]
Monthly child support payment (from line 10 of DR-306) to be paid each month
except
= $
to be paid by
mother
father.
c. Divided Custody. Each parent will have primary custody of one or more of the
children and the parents will not share custody of any of the children. [Attach form
DR-307 to show your calculations.]
Monthly child support payment (from line 7 of DR-307) = $
to be paid by
mother
father.
d. Hybrid Custody. [Attach form DR-308 to show your calculations.]
Monthly child support payment (from line 8 of DR-308) = $
to be paid by
mother
father.
4. Health Care Coverage
a. Health Insurance.
(1)
Does father have health insurance available for the child(ren) at reasonable cost
through his employer, union or otherwise?
Yes
No
(2)
Does mother have health insurance available for the child(ren) at reasonable cost
through her employer, union or otherwise?
Yes
No
(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:
If the answer to (3) and (4) is no, one of the parents must agree to provide insurance for
the child(ren) if such insurance is available at reasonable cost. The cost of the
children’s insurance must be divided equally by the parents unless the court orders
another division for good cause.
Husband’s Signature
Wife’s Signature
Page 10 of 15
DR-105 (4/09)(cs)
AS 25.24.200-.260
PETITION FOR DISSOLUTION OF MARRIAGE (WITH CHILDREN)
Civil Rule 90.1(a), f(2)(A)(B), (i)(1)
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