Form Dc 628 – Fill Out and Use This PDF

ORDER OF SUPPORT (CIVIL)		This Court’s Case No
Commonwealth of Virginia		DCSE ID No
[ ] TEMPORARY ORDER	[ ] FINAL ORDER

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court

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STREET ADDRESS OF COURT

Petitioner:	v.	Respondent:
[ ] Identifying information not provided for good cause shown		[ ] Identifying information not provided for good cause shown
Residential Address:		Residential Address:
Residential Telephone No.:		Residential Telephone No.:
Mailing Address if Different:		Mailing Address if Different:
Social Security No. (last 4 digits only):		Social Security No. (last 4 digits only):
Driver’s Lic. No. & State:		Driver’s Lic. No. & State:
Date of Birth:		Date of Birth:
Employer:		Employer:
Address:		Address:
Telephone No.:		Telephone No.:

[] This case is DISMISSED without prejudice because the Respondent could not be located for service of process.

[] Upon hearing the evidence, the Court finds for the Respondent and ORDERS that the case be DISMISSED.

PRESENT: [ ] Petitioner	[ ] Attorney/ Guardian Ad Litem for Petitioner [ ] DCSE Representative	[	] Attorney for DCSE
[ ] Respondent	[ ] Attorney/ Guardian Ad Litem for Respondent [ ] Guardian Ad Litem for child(ren) [		] Other

[] Upon hearing the evidence, the Court finds that [ ] this (these) dependents [ ] a parent of the Respondent in necessitous circumstances:

NAME

SOC. SEC. # (last 4 digits only)

SEX

DATE OF BIRTH

RELATIONSHIP TO RESPONDENT

is (are) entitled to support from the Respondent, and that the Respondent is chargeable with support as alleged in the petition. Therefore, the Court ORDERS the Respondent to pay:

[	] $	. . . . . . per month CURRENT CHILD SUPPORT effective		for all children listed above; OR
[	] $	. . . . . . per month CURRENT CHILD SUPPORT effective		divided among the above-listed
children as follows:
	$	. . . . . . . . . . . . . for	$	for
	$	. . . . . . . . . . . . . for	$	for
[	] $	. . . . . per month CURRENT SPOUSAL SUPPORT effective		. . .
[	] $	. . . . . per month COMBINED CHILD-SPOUSAL (UNITARY) SUPPORT effective
[	] $	. . . . . per month SUPPORT FOR A PARENT effective
[	] $	. . . . . per month PAYMENT TOWARDS ARREARAGES OF $		. . . . . . . . . . .
TOTAL $		per month payable, first payment due on the 1st day of ……………………., and each subsequent payment

is due on the 1st day of each month thereafter. Payments may be made in intervals of ………………….., per ……………….., beginning

DATE

All support paid shall be credited to current support first and the remainder shall be credited to arrearages.

Child support shall terminate on a child’s eighteenth birthday; however, support shall continue for any child who is over the age of eighteen and (i) a full-time high school student, (ii) not self-supporting and (iii) living in the home of the parent receiving child support, until the child reaches the age of nineteen or graduates from high school, whichever occurs first; and if any arrearages for child support, including interest or fees, exist at the time the youngest child emancipates, payments shall continue in the total amount due until all arrearages are paid. If the above current child support is not divided per child, the ordered amount cannot be changed except by a court.

[ ] Continuing support for	, a child whom the court has determined (i) is severely and permanently mentally
	Name of Child
or physically disabled, (ii)	is unable to live independently and support himself and (iii) resides in the home of the parent seeking support.

FORM DC-628 (PAGE ONE OF THREE) 07/10

ORDER OF SUPPORT (CIVIL)

Case No

ARREARAGES:

[ ] No arrearages exist as of . . . . . . . . . . . . . . . . . .

[ ] $ . . . . . . . . . . . . . . . . . child support arrearage owed by Respondent. [ ] $ . . . . . . . . . . . . . . . . . spousal support arrearage owed by Respondent.

[ ] $ . . . . . . . . . . . . . . . . . unitary (child/spousal) support arrearage owed by Respondent.

[ ] $

total SUPPORT arrears owed by Respondent [ ] with interest included [ ] without interest included

[] arrears include an assessment from the effective date of this order to the first payment due date.

[ ] This total includes TANF debt or other public funds paid prior to the effective date of this order of $ . . . . . . . . . . . . . . . . .

for . . . . . . . . . . . . months.

These arrearages are calculated as of the date of this Order including support owed for the current month. This amount does not include

payments made after ____/____/____, and respondent shall be credited for any payments made thereafter. Interest shall continue to accrue

on unpaid arrearages at the judgment rate unless the petitioner, in a writing submitted to the court, waives the collection of interest.

PAYMENT:

Payment shall be made payable to:

[] Petitioner at the address shown in the beginning of the Order.

The parties shall give the court at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the court informed of the name, address, and telephone number of his/her current employer.

[] Treasurer of Virginia and sent to Virginia Department of Social Services, Division of Child Support Enforcement, P.O. Box 570, Richmond, Virginia 23218-0570 unless otherwise instructed by that agency or this Court and shall contain the following:

1.Check or money order made payable to the Treasurer of Virginia.

2.Print on the check or money order:

Your name and social security number

Petitioner’s name as shown on the first page of this order

The DCSE ID No. shown on the first page of this order. If no such number is shown, use this Court’s name and case number as shown on the front page of this order until that number is sent to you; then start using the DCSE ID No.

The parties shall give to the Virginia Department of Social Services and the court, at least 30 days written notice, in advance, of any proposed change of residential and, if different, mailing address and of any change of telephone number within 30 days of the change. The Respondent is required to keep the Virginia Department of Social Services and the court informed of the name, address and telephone number of his/her current employer.

[] The parties shall also give each other at least 30 days written notice, in advance of any change of residential and, if different, mailing address and of any change in telephone number within 30 days after the change.

WARNING: Failure to pay in accordance with this order is a violation of this order and may be punished by a jail sentence or a fine or both. In addition, you may not receive credit for payments made contrary to the payment instructions provided in this order. Whenever income withholding is authorized, it is your responsibility to make the payment to DCSE until the income withholding becomes effective. You are responsible for keeping records of payments you make.

HEALTH CARE PROVISIONS:

[] Respondent [ ] Petitioner shall provide health care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents

[] Respondent [ ] Petitioner shall provide dental care coverage for the [ ] child(ren) [ ] spouse and shall deliver the document necessary for the use of such coverage by the dependents

[] Respondent [ ] Petitioner presently has health care coverage and is ordered to maintain it or comparable coverage.

Health Insurance Company	Policy name
Name of Policy Holder	Policy number

In the event of any change in health insurance, the responsible party is required to notify the opposing party of the change. The responsible party shall inform the Virginia Department of Social Services, if support payments are ordered to be paid through the Virginia Department of Social Services, or the opposing party, if support payments are ordered to be paid directly to the opposing party, of any changes in the availability of the health care coverage for the minor child or children.

[] The Court finds that “health care coverage” as defined by the statute is not available at “reasonable cost” as defined by statute, and therefore, the Court does not order either the Respondent or the Petitioner to provide health care coverage.

[] Any reasonable and necessary unreimbursed medical and dental expenses for each child covered by this order shall be paid in the

following manner: . . . . . . . . . . . . . . % Respondent . . . . . . . . . . . . . % Petitioner.

FORM DC-628 (PAGE TWO OF THREE) 07/14

ORDER OF SUPPORT (CIVIL) Case No. .............................................

[ ] Respondent [ ] Petitioner is ordered to execute the appropriate tax forms or waivers to grant the other party the right to take the

income tax dependency exemption for tax years . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHILD OR CHILDREN

for federal and state income tax purposes.

[] The Court finds that a license, certificate, registration or other authorization to engage in a profession, business, trade, occupation, or

recreational activity issued by the Commonwealth of Virginia is held by

TYPE OF LICENSE

AGENCY GRANTING LICENSE

LICENSE NUMBER

Upon a delinquency of a support payment for a period of 90 days or more, or in an amount of $5,000 or more, a petition may be filed for suspension of any license, certificate, registration or other authorization to engage in a profession, trade, business, occupation, or recreational activity issued by the Commonwealth. Virginia Code § 20-60.3.

[ ] Withholding from income is ordered payable through the Virginia Department of Social Services by [ ] court income deduction order or [ ] administrative order for income withholding.

[] Immediate withholding from income is not ordered, pursuant to a written agreement between the parties or for good cause shown. It is further ORDERED that:

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[	] This Order was determined based on [	] sole [ ] shared [ ] split custody guidelines.
[	] A child support award of $	. . . . . . . . . . . . by application of the guidelines provided in Virginia Code § 20-108.2 would be
	unjust or inappropriate in this case as determined by the relevant evidence pertaining to the factors set forth in the attached supplement
	which is incorporated herein by reference, the ability of each party to provide child support, and the best interest of the child.

[] Entered in accordance with the parties’ written stipulation or agreement.

[	] The Respondent is also required to post with the Clerk a recognizance pursuant to § 20-114 of $		with/without surety
[	] The Respondent shall also pay: $	reimbursement of costs to the Petitioner due . .	. . . . . . . . .
	$	attorneys’ fees to the Petitioner’s attorney due	. . . . . . . . . . . . . . . . . .

If arrearage amount equals or exceeds 3 months owed, reasonable attorneys’ fees must be ordered pursuant to Virginia Code § 16.1-278.18, and may be ordered pursuant to § 20-78.2.

NOTICE: Support payments may be withheld as they become due from income without further amendment of this order or having to file an application for services with the Virginia Department of Social Services. Such order shall only be entered upon motion after proper notice sent by the clerk or counsel. Support payments may be withheld without further amendment of this order upon application for services with the Virginia Department of Social Services. In determining a support obligation, the support obligation as it becomes due and unpaid creates a judgment by operation of law. Failure to make payments when due means that interest will accrue according to Virginia Code § 6.1- 330.54.

The Virginia Department of Social Services may initiate a review of the amount of support ordered by any court. If a change in circumstances, as defined in the State Board of Social Services’ regulations, has occurred, the Department shall report its findings and a proposed modified order to the court which entered the order. Notice shall be served on both parties. Either party may request a hearing on the proposed modified order by filing a request with such court within 30 days of receipt of notice by the requesting party. Unless a hearing is requested with the time limits, no hearing shall be required and the modified order shall be effective 30 days after the notice is received and shall amend any prior court order. Virginia Code § 20-60.3.

In cases enforced by the Virginia Department of Social Services, the Department of Motor Vehicles may suspend or refuse to renew the driver’s license of any person upon receipt of notice from the Virginia Department of Social Services that the person is delinquent in the payment of child support by 90 days or in an amount of $5,000 or more, or the person has failed to comply with a subpoena, summons, or warrant relating to paternity or child support proceedings.

If the order being reviewed by the Department deviates from the guidelines, based on one or more factors set out in Virginia Code § 20-108.1, a hearing shall be scheduled with the court which entered the order.

THIS ORDER SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL AMENDED OR ANNULLED BY THIS COURT OR A COURT OF COMPETENT JURISDICTION TO WHICH AN APPEAL MAY BE TAKEN.

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DATE	JUDGE

SEEN AND AGREED AS TO NO PROVISION FOR INCOME WITHHOLDING.

FORM DC-628 (PAGE THREE OF THREE) 07/09