Children

a. Child Support

Information about the current support order I want to change. Fill in the information about your current Child Support Describe the child support order you have now, including the current amount and how often it is paid. Name Write the full name of your first child shared with the other party.

b. Children's Basic Information

Date of Birth Write the birth date of your first child. Name Write the full name of your second child shared with the other party. Date of Birth Write the birth date of your second child. Name Write the full name of your third child shared with the other party. Date of Birth Write the birth date of your third child. Name Write the full name of your fourth child shared with the other party. Date of Birth Write the birth date of your fourth child. Name Write the full name of another person you help support financially. Age Write how old this person is. Relationship to You Tell how this person is related to you, such as parent or stepchild. Reside With You (Y/N) Write Y if this person lives with you, or N if they do not. Court Order to Support (Y/N) Write Y if a court ordered you to support this person, or N if not.

c. Health & Medical Support

Do you have health insurance available? Check Yes if you can get health insurance for yourself or your kids, or No if you cannot. Are you enrolled? Tell whether you are actually signed up for the health insurance right now. Total monthly cost Write the full amount you pay each month for this health insurance plan. Premium cost to insure you alone Write how much it costs each month to cover just yourself with no one else added. Premium cost to insure child(ren) common to the parties Write the monthly cost to cover only the children you and the other parent share. List all people covered by your insurance coverage: List the names of everyone who is covered under your health insurance plan. Name of insurance company and Policy/Group Number: Write the name of the insurance company and your policy or group number from your insurance card. Total monthly cost Write the full amount you pay each month for dental or vision insurance. Premium cost to insure you alone Write how much it costs each month to cover just yourself with no one else added. Premium cost to insure child(ren) common to the parties Write the monthly cost to cover only the children you and the other parent share. List all people covered by your insurance coverage: List the names of everyone who is covered under your dental or vision plan. Name of insurance company and Policy/Group Number: Write the name of the dental or vision insurance company and your policy or group number from your card. Name(s) of child(ren) cared for and amount per child: Write the name of the first child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for that child's care. Name(s) of child(ren) cared for and amount per child: Write the name of the second child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for that child's care. Name(s) of child(ren) cared for and amount per child: Write the name of the third child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for that child's care. Name(s) and address(es) of child care provider(s): List the name and address of each person or place that provides the child care.

d. Child Support

Court ordered current child support for child(ren) not common to the parties Enter the monthly child support a court ordered you to pay for children who are not shared with the other party in this case.

e. Health & Medical Support

Court ordered cash medical support for child(ren) not common to the parties Enter the monthly cash medical support a court ordered you to pay for children not shared with the other party. Amount of any arrears payment Enter how much you pay each month toward past-due support you still owe. Amount per month actually paid in last 12 mos. Enter the amount you have actually paid each month over the past year. Attach proof of your payments. Name(s) and relationship of minor child(ren) who you support or who live with you, but are not common to the parties. List any children you support or who live with you that you and the other party do NOT share. Include each child's name and how they are related to you. Name Write the full name of your first child that you and the other party have together.

f. Children's Basic Information

Date of Birth Enter the birth date of your first child. Name Write the full name of your second child that you and the other party have together. Date of Birth Enter the birth date of your second child. Name Write the full name of your third child that you and the other party have together. Date of Birth Enter the birth date of your third child. Name Write the full name of your fourth child that you and the other party have together. Date of Birth Enter the birth date of your fourth child. Name Write the full name of another person you help support. Age Write how old that person is. Relationship to You Tell how this person is related to you, like parent or stepchild. Reside With You (Y/N) Write Y if this person lives with you, or N if they do not. Court Order to Support (Y/N) Write Y if a court ordered you to support this person, or N if not.

g. Health & Medical Support

Do you have health insurance available? Yes Check this box if you can get health insurance, such as through your job. Do you have health insurance available? No Check this box if you cannot get health insurance through your job or any other plan. Are you enrolled? Write yes or no to show if you are actually signed up for health insurance right now. 1. Total monthly cost Write how much you pay each month for your full health insurance plan. 2. Premium cost to insure you alone Write the monthly cost to cover only yourself, with no one else added. 3. Premium cost to insure child(ren) common to the parties Write the monthly cost to cover the children you share with the other parent. 4. List all people covered by your insurance coverage: List the names of everyone who has health insurance through your plan. 5. Name of insurance company and Policy/Group Number: Write the name of your health insurance company and your policy or group number. Look on your insurance card. 1. Total monthly cost Write how much you pay each month for your full dental or vision plan. 2. Premium cost to insure you alone Write the monthly cost to cover only yourself for dental or vision. 3. Premium cost to insure child(ren) common to the parties Write the monthly cost to cover the children you share with the other parent for dental or vision. 4. List all people covered by your insurance coverage: List the names of everyone who has dental or vision insurance through your plan. 5. Name of insurance company and Policy/Group Number: Write the name of your dental or vision insurance company and your policy or group number. Look on your insurance card. Name(s) of child(ren) cared for and amount per child: Write the name of the first child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for this child's care. Name(s) of child(ren) cared for and amount per child: Write the name of the second child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for this child's care. Name(s) of child(ren) cared for and amount per child: Write the name of the third child who receives child care. Name(s) of child(ren) cared for and amount per child: Enter how much you pay each month for this child's care. Name(s) and address(es) of child care provider(s): Write the name and address of each person or place that provides the child care. Name(s) and relationship of minor child(ren) who you support or who live with you, but are not common to the parties. List any children under 18 who live with you or that you support, but who are not children you share with the other party. Include each child's name and how they are related to you.