Form Aoc-152-Uniform Child Support Order
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2AOC-152
Doc Code: OSUP
Case No.____________________
Rev. 4-13
OSUPW
Court
[
] District
l e x
Page 1 of 2
e t
j u s t i t i a
[
] Circuit
Commonwealth of Kentucky
[
] Family
UNIFORM CHILD SUPPORT ORDER AND/OR
Court of Justice
County ______________________
WAGE/INCOME WITHHOLDING ORDER
* See Footnotes & Additional
[ ] NEW ORDER
[ ] AMENDED ORDER
IV-D Case No. ________________
Information
[ ] ORDER FOR WAGE/INCOME WITHHOLDING
NOTICE: The Federal Income Withholding For Support Form OMB 0970-0154 must be used by private parties or their attorneys in non-IV-D eligible
cases to notify an employer/income withholder of any wage/income withholding ordered herein.
_______________________________________________________________________________________________
Plaintiff/Petitioner Name
Birthdate
SSN
_______________________________________________________________________________________________
Defendant/Respondent Name
Birthdate
SSN
In Re: Child’s Name _____________________________________________________________________________
Social Security No. _____________________
Birthdate __________________________
Child’s Name _____________________________________________________________________________
Social Security No. _____________________
Birthdate __________________________
If there are more than two (2) children, attach separate sheet with identifying information and check here [ ]. Said
attachment is incorporated into this Order by reference.
IT IS HEREBY ORDERED AND ADJUDGED THAT: The [ ] Mother [ ] Father [ ] Other _________________
___________________________________________ shall pay child support as follows:
1)
$__________ per month as current child support effective ____________________, ______: [ ] As determined
by KY Child Support Guidelines; [ ] By written agreement of parties with knowledge of the Guidelines;
[ ] Upon a finding that application of the Guidelines would be unjust or inappropriate because: __________________
___________________________________________________________________________________________.
2)
$__________ per month toward arrearage judgment totaling $______________, calculated for period beginning
_________________________, ______ and ending ___________________________, ______.
3)
[
] Health insurance is currently accessible and reasonable in cost. The [
] Mother [
] Father is ordered to
provide and maintain health insurance coverage for the minor child(ren). [
] Health insurance is not currently
accessible and reasonable in cost but shall be provided by the [
] Mother [
] Father when it becomes
accessible and reasonable in cost. Extraordinary medical expenses shall be paid as follows: _________________.
4)
$__________ per month for other expenses: _______________________________________________________
___________________________________________________________________________________________.
$__________ TOTAL MONTHLY AMOUNT to be paid at:
5)
$ _________ per [ ] week [ ] bi-weekly [ ] semi-monthly [ ] month
1
6)
Other conditions: _____________________________________________________________________________
_______________________________________________________________________________________________.
DOMESTIC VIOLENCE
-
Child Support Recipient's Name & Address
2
PROTECTIVE ORDER
_________________________________________________________
ISSUED [ ] YES [ ] NO
_________________________________________________________
_________________________________________________________
PROTECTED PARTY:
_________________________________________________________
[
] PETITIONER
[
] RESPONDENT
If child support is paid by wage withholding, a job change may affect the frequency and amount of wages to be withheld in
1
order to meet the monthly obligation amount.
Child support recipient may elect not to provide address information in this section but in order to be properly disbursed his/her
2
mailing address must be provided to the child support agency.
C
C
,
.
HILD SUPPORT SHALL CONTINUE IN FULL FORCE AND EFFECT UNLESS MODIFIED by THE
OURT
OR ENDED by OPERATION OF LAW
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