The parent ordered to pay support must pay child support for the past periods and in the amounts set forth below:
Name of child
Date of birth Period of support Amount
(1)
Other (specify):
(3)
Interest accrues on the entire principal balance owing and not on each installment as it becomes due.
(2)
day of each month
For a total of: $
payable: $
on the:
beginning (date):
(2)
Interest is not included and is not waived.
day of each month
Interest accrues on the entire principal balance owing and not on each installment as it becomes due.
Child support: $ Spousal support: $ Family support: $
Payable: $ on the:
beginning (date):
(3)
(4)
(1)
The parent ordered to pay support
The parent receiving support must (1) provide and maintain health insurance
coverage for the children, if available at no or reasonable cost, and keep the local child support agency informed of the
availability of the coverage (the cost is presumed to be reasonable if it does not exceed 5 percent of gross income to add
a child); (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the local
child support agency’s request, complete and return a health insurance form; (4) provide to the local child support agency
all information and forms necessary to obtain health-care services for the children; (5) present any claim to secure
payment or reimbursement to the other parent or caretaker who incurs costs for health-care services for the children; and
(6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the
children. The parent ordered to provide health insurance must seek continuation of coverage for the child after the child
attains the age when the child is no longer considered eligible for coverage as a dependent under the insurance contract,
if the child is incapable of self-sustaining employment because of a physically or mentally disabling injury, illness, or
condition and is chiefly dependent upon the parent providing health insurance for support and maintenance.
The parent ordered to pay support owes support arrears as follows, as of (date):
f.
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FL-665 [Rev. January 1, 2017]
FINDINGS AND RECOMMENDATION OF COMMISSIONER
(Governmental)
e.
Any support ordered will continue until further order of court, unless terminated by operation of law.(5)
d.
(6)
When a person who has been ordered to pay child support is in jail or prison or is involuntarily institutionalized for any
period of more than 90 days in a row, the child support order is temporarily stopped. However, the child support order will
not be stopped if the person who owes support has the financial ability to pay that support while in jail, prison, or an
institution. It will also not be stopped if the reason the person is in jail, prison, or an institution is because the person didn't
pay court ordered child support or committed domestic violence against the supported person or child. The child support
order starts again on the first day of the month after the person is released from jail, prison, or an institution.
5.
c.
(3)
(4)
day of each monthFor a total of: $ payable on the:
beginning (date):
Other (specify):
The low-income adjustment applies.
The low-income adjustment does not apply because (specify reasons):
(2)
FL-665
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER: