Judgment Information:
st
$ ______________ per _______________ for child support; Effective Date (Date 1
Payment Due) ______________
$ ______________ per _______________ for spousal support (maintenance); Effective Date ____________________
$ ______________ per _______________ for periodic arrearage payments toward arrearage judgment of $ ____________
$ ______________ per _______________ for state debt judgment of $ ___________________
Payments are to be made to the Family Support Payment Center.
Payments are to be made directly to the custodial parent.
Has Medical Insurance been ordered?
Yes
No. If yes, who is ordered to pay? _____________________________
If no, why?
Parties agree no insurance ordered.
Child covered in another order.
Per Court no health insurance ordered.
Order silent, no mention of medical insurance in order.
Children:
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Name: _______________________________________
SSN: ___________________ DOB: _____________________
Optional: MACSS Member Number (to be completed by the court): ___________________________________________
Check if more than ten children and attach additional sheet
I certify the information above is correct to the best of my knowledge.
__________________________________________________________________
Signature of Preparer
Instructions to Clerk
Maintain the closed portion(s) of the record in a sealed manila envelope within the file. The file
can be maintained with other open records. If a request is made to review the open portion of the
file, the envelope can be removed from the file. Access to the record must be restricted to avoid
access to the closed portion of the record.
OSCA (4-10) CS15
2 of 2
CCFC204
01/11