Form 4A-303. Child support obligation and order.

STATE OF NEW MEXICO COUNTY OF ___________________________ ____________________ JUDICIAL DISTRICT _______________________________________, Petitioner, v. No. _________________ _______________________________________, Respondent. CHILD SUPPORT OBLIGATION AND ORDER1 _____________________ and ____________________ are the parents of the children listed below. I. IDENTIFICATION AND CONTACT INFORMATION Parent’s name Physical address and phone number Place of employment and phone number _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ Child’s name Year of birth Age _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ ______ ____________ ____________ ____________ [ ] The parents shall advise each other of any change to this contact information within ten (10) days of new information becoming available. II. CHILD SUPPORT2 A. Child Support Worksheet.3 A signed child support worksheet is attached to this plan. (Com Child support: ________________ pays ________________ $____________ per month. the youngest child turns eighteen (18); however, if the youngest child turns eighteen (18) wh (Choose 1 or 2) [ ] 1. This amount is the amount shown on the worksheet; (Or) [ ] 2. This is a deviation from the amount shown on the child support worksheet becau ________________________________________________________________ B. Health insurance coverage6 (Choose 1, 2, or 3) [ ] 1. ____________________ (name of parent) shall keep the minor children covere (Or) [ ] 2. Neither parent has private health or dental insurance coverage available at a rea Mexico, Child Support Enforcement Division ("CSED"), has been given sufficien (Or) [ ] 3. Other health insurance coverage shall be provided as follows: ________________________________________________________________ _____. C. Additional healthcare expenses to be determined by percentage. The parents shall spli D. Wage withholding of child support. (Choose and complete 1 or 2) [ ] 1. Withhold wages for child support. Child support payment shall be withheld fro (Choose a or b) [ ] a. Attached is a completed Form 4A-304 NMRA Wage With (Or) [ ] b. ____________________ (name of parent) shall take a co (Or) [ ] 2. Other plan. Wage withholding is not appropriate at this time as the parents hav ________________________________________________________________ _____. E. Health and dental insurance. The parents shall do the following: 1. follow the insurance plan in selecting a doctor or dentist; 2. use doctors and dentists who are part of the insurance plan; 3. make sure each parent has a copy of the insurance card and policy; and 4. cooperate and work together to promptly submit all insurance forms. F. Exchange of information. Once a year either parent can ask, in writing, for both parents to 1. federal and state tax returns for the prior year; 2. W-2 statements for the prior year; 3. IRS form 1099s for the prior year; 4. work related day care statements for the prior year; 5. dependent medical insurance premiums for the prior year; and 6. wage and payroll statements for the four months prior to the request. G. Tax issues.9 This is the plan about tax issues, such as the dependency exemption, that rela [ ] Follow IRS regulations; or [ ] Adopt another plan as follows: ____________________________________________________________________ H. Other expenses. Each parent shall provide the children with items they need while they are [ ] (If applicable) The parents shall pay for special activities as follows: ____________________________________________________________________ VERIFICATION I affirm under oath and penalty of perjury under the laws of the State of New Mexico that I have read this document, that I agree with everything in it, and that the statements in it are true and correct to the best of my knowledge and belief. _________________________________ ______ Name of parent (print) _________________________________ ______ Parent’s signature _________________________________ ______ Mailing address _________________________________ ______ Telephone _________________________________ ______ Name of parent (print) _________________________________ ______ Parent’s signature _________________________________ ______ Mailing address _________________________________ ______ Telephone STATE OF NEW MEXICO ) COUNTY OF __________________ ) ss. Acknowledged, signed and sworn to before me this _____ day of _____________, _____ by _______________________, the parent. _________________________ Notary public My commission expires: __________________. STATE OF NEW MEXICO ) COUNTY OF __________________ ) ss. Acknowledged, signed and sworn to before me this _____ day of _____________, _____ by _______________________, the parent. _________________________ Notary public My commission expires: __________________. Approved, adopted, and ordered by the District Court ________________________ Date _______________________________________ District Court Judge