Fillable State of Montana Case Registry and Vital Statistic (State of Montana)

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State of Montana Case Registry and Vital Statistic (State of Montana)

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State of Montana Case Registry and Vital Statistic Reporting Form
Department of Public Health and Human Services
INSTRUCTIONS
Order Information: Check the box that most accurately describes the type of order being entered. If it is
dissolution of marriage, enter the place of marriage and indicate if child support is ordered. Temporary
support orders and paternity orders that contain child support are categorized as “child support order,
without dissolution.” “Child support order” includes medical support orders. If the order does not contain a
child support order, social security numbers of the parties are not required and only Parts 1, 2 and 9 needs to
be completed.
Parts 1 and 2: Provide information about the parties to the order. If there is a child support order, be sure to
check the box that shows whether the party owes support (payor) or will receive support (payee). If a party is
ordered to both pay and receive support, check the box labeled “both.” If there is no support order, check the
box labeled “N/A” for not applicable. If a party is ordered to pay $0 support, that party should be considered a
payor.
Part 3: Provide information about the children named in the order and indicate which parent or other party
the children live with. If the parenting plan provides for shared residential parenting, circle “B” for both. If a
child is not living with either parent, circle “O” and list the child’s name and address.
Part 4: Complete this part if support is ordered to be paid to an agency or an individual other than a parent.
Part 5: Indicate whether any of the parties are protected from each other by a protective or restraining order.
If yes, list the names of the protected parties. This includes any protected children.
Part 6: Provide information about the employment or other source of income of the party who is ordered to
pay child support. If both parties are ordered to pay support, skip Part 6 and complete Part 10 instead.
Part 7: Provide information about the support order. Check the type(s) of support ordered and enter the amount
and how often it is due. (Example: $100 per week.) All orders should have a “begin” date; many will not have an
“end” date. If both parties are ordered to pay support, skip Part 7 and complete Part 11 instead.
If the order enters a judgment for past due support, show the total amount of the judgment. If the judgment
includes amounts for penalties, fees or interest, list those amounts on the appropriate lines.
List any special conditions of the support order. (Example: support is due until the child graduates from
college.) Copy the information requested about the guidelines to this form from the guidelines worksheet.
Part 8: Provide information about health insurance coverage for the children. If insurance is not provided,
indicate whether it is available through the employer of either parent. Relationship of the party providing
insurance is the party’s relationship to the children. (Example: mother, father, mother’s spouse, father’s
spouse.)
List the terms and conditions of the insurance coverage. (Example: 80/20 plan, $500 deductible, major medical
only.)
Part 9: Provide information about the person completing this form.
Part 10: Employment information for multiple payors. Complete only if both parties are ordered to pay
support. See Part 6 instructions.
Part 11: Order information for multiple payors. Complete only if both parties are ordered to pay support. See
Part 7 instructions
July 23,2019
STATE OF MONTANA CASE REGISTRY AND VITAL STATISTICS REPORTING FORM
(See instructions on first page)
County/Tribe Judicial District No. Cause No.
Date Decree/OrderSigned
☐
Dissolution of Marriage
County that Issued Marriage License:
City, County, State of Marriage:
Date of Marriage:
☐
With Child Support Order
☐
Without Child Support Order (complete Parts 1, 2 & 9 only)
☐
Modification of Child Support Order
☐
Child Support Order, without Dissolution (Includes
Temporary Support Orders and Paternity Orders with
Child Support)
☐
Legal Separation with Child Support Order
☐
Dependent Neglect/Juvenile Delinquency
☐
Invalid Marriage-Specify Legal grounds for Action:
1 Spouse/Parent 1:
Name: SSN Telephone#:
Last First Middle/Suffix
Mailing Address:
Street City State Zip
Residential Address (if different from above):
Date of Birth: Place of Birth: Race:
State/Foreign Country
Driver’s License#/State Occupation:
Number of this marriage (1
st
,2
nd
, etc.): Date, City & State of previous marriage(s):
2 Spouse/Parent 2:
Name: SSN Telephone#:
Last First Middle/Suffix
Mailing Address:
Street City State Zip
Residential Address (if different from above):
Date of Birth: Place of Birth: Race:
State/Foreign Country
Driver’s License#/State Occupation:
Number of this marriage (1
st
,2
nd
, etc.): Date, City & State of previous marriage(s):
☐ Payor ☐ Payee ☐ Both ☐ N/A Former Name:
☐ Payor ☐ Payee ☐ Both ☐ N/A Former Name:
☐
Other Payee: If support is to be paid to another payee, check here and complete Part 4.
3 Names of Children Included in the Support Order:
Last
First
Middle
Date of Birth
Gender
SSN
If any of the above-named children are not residing with a parent, list the child’s name and address:
-2-
July 23,2019
I I I I I I I
4 Other Payee:
Name of person/agency owed support if not a parent:
Last Name or Agency First Name Middle
Mailing Address:
Street
City
State
Zip
Residential Address (if different from above):
5 Protective Order:
Is a party to this action protected from another party to the action by an order of protection?
☐
Yes ☐ No If yes, enter name(s) of protected party(ies):
6 Employer/Income Source Information:
Provide information about the payor’s employment or periodic source of income. (Attach additional pages if needed)
☐
Check here if this order requires both parties to pay support. If checked, skip Parts 6 & 7, and complete Parts 8, 9,10 & 11.
Name of Employer or Sourceof Income Telephone #
7 Support Order Date Order Signed:
Chose type of support and enter appropriate information. If applicable, arrears due at time oforder:$
Support Type
Total Due
Frequency
Begin Date
End Date
Judgment
Penalty
Fees*
Interest*
☐
Child Support:
$
$
$
$
$
☐
Medical Support
$
$
$
$
$
☐
Spousal Support:
$
$
$
$
$
(Alimony)
(*list amounts included in judgment)
Is payor exempt from income withholding under MCA 40-5-315? ☐ Yes ☐ No ☐ Tribal Order
List any special terms/conditions of thesupport order(s):
Was Parent 1 represented by an attorney? ☐ Yes ☐ No Was Parent 2 represented by an attorney? ☐ Yes ☐ No
Information from child support guidelines worksheet:
Parent 1:“Income after deductions” $
Parent 2:“Income after deductions” $
“Credit for Payment of Expenses”$
“Credit for Payment of Expenses”$
8 Health Insurance: (Attach additional pages if
needed.)
Is health insurance provided for the children?
☐ Yes
☐
No (If no, answer last question in this section)
Name and relationship of party providing insurance:_______________________________________
Policy No.
Name of insurance carrier or health benefit plan:
Address of insurance carrier or health benefitplan:
Names of children covered:
Terms/conditions ofcoverage:
If children are not covered, is coverage available through
Parent 1 employer?
☐ Yes
☐ No
Parent 2 employer?
☐ Yes
☐ No
9 This form was completed by: Name/Title:
Telephone #: Signature: Date
Complete next page if both parties are ordered to pay child support
Information contained in this form is private and confidential.
It may only be shared with courts, agencies and individuals authorized by MCA 40-5-923.
-3-
July 23,2019
--------------------------------------------------------------------------------------------------------
□
□
□
Multiple Payors: Complete Parts 10 and 11 only if the order requires both parties to pay support.
10--Parent 1--Employer/Income Source Information:
Provide information about parent 1 employment or periodic source of income. (Attach additional pages if needed.)
Name of Employer or Sourceof Income Telephone #
Street City State Zip
10--Parent 2--Employer/Income Source Information:
Provide information about parent 2 employment or periodic source of income. (Attach additional pages if needed.)
Name of Employer or Sourceof Income Telephone #
Street City State Zip
11--Parent 1--Support Order Date Order Signed:
Parent 1 Support Obligation:
If applicable, arrears due at timeof order:$
Support Type
Total Due
Frequency
Begin Date
End Date
Judgment
Penalty
Fees*
Interest*
☐
Child Support:
$
$
$
$
$
☐
Medical Support
$
$
$
$
$
☐
Spousal Support:
$
$
$
$
$
(Alimony) (*list amounts in included in judgment)
Is Parent 1 exempt from income withholding under MCA 40-5-315? ☐ Yes ☐ No ☐ Tribal Order
11--Parent 2--Support Order Date Order Signed:
Parent 2 Support Obligation: If applicable, arrears due at time oforder:$
Support Type
Total Due
Frequency
Begin Date
End Date
Judgment
Penalty
Fees*
Interest*
Child Support:
$
$
$
$
$
Medical Support
$
$
$
$
$
Spousal Support:
$
$
$
$
$
(Alimony) (*list amounts in included in judgment)
Is Parent 2 exempt from income withholding under MCA 40-5-315? ☐ Yes ☐ No ☐ Tribal Order
List any special terms/conditions of the support order(s):
Was Parent 1 representedby an attorney? ☐ Yes ☐ No Was Parent 2 represented by an attorney? ☐ Yes ☐ No
Information from child support guidelines worksheet:
Parent 1: “Income after deductions”: $
“Credit for Payment of Expenses”:$
Parent 2: “Income after deductions”: $
“Credit for Payment of Expenses”:$
-4-
July 23,2019
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State of Montana Case Registry and Vital Statistic (State of Montana)

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Completed 28 December 2022

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