Uniform Order For Support Form - Lake County, Illinois Page 3
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4Case No. _______________________
TERMINATION
This obligation to pay child support terminates on ______________________
unless modified by written
(mmddyyyy)
order of the Court. (Insert a date no earlier than the date that the youngest child reaches the age of 18 or is expected to
graduate from high school, whichever comes later.) This termination date does not apply to any arrearage that may
remain unpaid on that date. The child(ren) covered by this order is/are:
INSURANCE
The obligor, obligee, obligor and obligee, shall provide health insurance for the child(ren) either by enrolling
them in any health insurance coverage available through the obligor’s, obligee’s, obligor’s and obligee’s,
employment or securing a private health insurance policy, accepted by the obligor and obligee or approved by the Court,
which names the child(ren) as beneficiary. Both the obligor and the obligee shall be provided a copy of the insurance policy
and the insurance card. The name of the health insurance provider and the number of the insurance policy regarding
dependent benefits/coverage on the date of this order are as follows:
Name of Health Insurance Provider (s):
Policy No.(s):
It is further ordered that:
The obligor shall give written notice to the Clerk of the Court, and if a party is receiving child and spouse services under
Article X of the Illinois Public Aid Code, to the Department of Healthcare & Family Services, within 7 days, of:
•
any new residential, mailing address or telephone number;
•
the name, address and phone number of any new employer, and;
•
the policy name and identifying number(s) of health insurance coverage available.
The obligor shall submit a written report of termination of employment and of new employment, including name and
address of the new employer, to the Clerk of the Court and the obligee within 10 days. Obligor and obligee shall advise
each other of a change of residence within 5 days except when the Court finds that the physical, mental or emotional health
of a party or that of a minor child, or both, would be seriously endangered by disclosure of the party’s address. An obligee
receiving payments through income withholding shall notify the Clerk of the Court and the State Disbursement Unit within 7
days, of a change in residence. The obligor and obligee shall report to the Clerk of the Court any change of information
included in the Child Support Data Sheet (Exhibit 1) within 5 business days of such change.
ADDITIONAL CONDITIONS OR FINDINGS
Child Support payment amount deviates from the amount required by statutory minimum guidelines. The amount of
support that would have been required under the guidelines is $________________. Reasons for deviation:
.
If there is an unpaid arrearage or delinquency equal to at least one month’s child support obligation on the termination
date, then the periodic amount required to be paid for current child support prior to the termination date shall
automatically continue to be an obligation toward satisfaction of the unpaid arrearage or delinquency until paid in full.
This payment shall be in addition to any periodic payment required for the satisfaction of the arrearage or delinquency
which shall continue until such amounts are paid in full.
Form approved by Conference of Chief Circuit Judges
Page 3 of 4
171-195 (Rev. 06/13)
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