Form 03en003e - Summary Of Support Order
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1
2IN THE DISTRICT COURT OF
COUNTY
STATE OF OKLAHOMA
)
)
Petitioner/plaintiff
)
Case no:
and
)
OCSS FGN:
)
(Oklahoma Child Support Services
Respondent/defendant
)
case number)
Summary of Support Order
Mail to:
OCSS, Central Case Registry, P.O. Box 248843, Oklahoma City, OK
73124-8843 or fax to: (405) 522-8901
This form must be completed and presented to the judge before the judge signs your
order. The Oklahoma Child Support Services Central Case Registry needs this
information to send child support payments. This form will NOT be put on file in the
Courthouse. [43 O.S. § 120]
/
/
1. The judge made the following order:
Temporary or
Final on
(date).
What kind of case was heard by the judge?
Divorce;
Paternity;
Juvenile;
Modification of earlier order;
Enforcement of earlier order; or
Other type of case, explain:
2. Active Protective Order?
Yes
No
3. The judge made the following support orders:
Amount
Payor
Begin date
End date
Child support
Cash medical
Fixed medical support
Spousal support
Arrearage payment
Other:
Total:
4. The judge ordered
father,
(name),
or
mother of the child(ren),
(name),
to provide health insurance for the child(ren), OR
cash medical support in lieu of insurance because health insurance is not
available at a reasonable cost. The judge said cash medical support should
be discontinued when the child(ren) is enrolled in health insurance at a
reasonable cost not to exceed $
.
5. Please fill in the boxes below about each child that the judge ordered support to be paid
for in this court order. If there are more than four children, please complete another form.
Federal law requires you to provide the information below. [42 U.S.C. § 666(a)(13)]
Form 03EN003E revised 4-29-2010 may continue on next page, page 1 of 2
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