Withholding Order Qualified Medical Child Support Order {DR 201}

DR Form 201 Eff. 1/1/2015 BUTLER COUNTY COMMON PLEAS COURT DIVISION OF DOMESTIC RELATIONS WITHHOLDING ORDER/QUALIFIED MEDICAL CHILD SUPPORT ORDER INFORMATION SHEET DATE: ____________ REQUESTED BY: ___________________________________ CASE NO. ________________________ OBLIGOR (PERSON ORDERED TO PAY): ______________________________________________________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: _______ SOCIAL SECURITY NUMBER: ______________________________________ PHONE: ____________________________ NAME AND ADDRESS OF EMPLOYER: EMPLOYER PHONE: _______________ PAY SCHEDULE: G Weekly PAYROLL ADDRESS: ________________________________ _______________________________ _______________________________ G Bi-weekly __________________________________ __________________________________ ___________________________________ G Monthly ZIP: _____________ DATE OF BIRTH: _________________________ G Semi-monthly MONTHLY OBLIGATION $ ___________ OBLIGATION PER PAY PERIOD $ FINANCIAL INSTITUTIONS NAME AND ADDRESS TYPE OF ACCOUNT ____________--__________________________ ACCOUNT NUMBER _ __________________________________________________________________________________________________________ _ ___________________________________________________________________________________________________________ _ ___________________________________________________________________________________________________________ OBLIGEE (PERSON/AGENCY TO RECEIVE PAYMENTS): _______________________________________________________ ZIP: _____________ DATE OF BIRTH: _________________________ G Non-IV-D ____________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: _______ SOCIAL SECURITY NUMBER: ______________________________________ PHONE: ________________________________________ CASE TYPE: G IV-D Non-ADC G IV-D ADC Number of minor children for whom support is paid (Alternate Recipients covered by insurance) CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: _________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ RESIDENTIAL PARENT/LEGAL GUARDIAN: ADDRESS: ______________________________________ CITY: __________________ STATE: ______ CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: ADDRESS: ______________________________________ CITY: __________________ STATE: ______ RESIDENTIAL PARENT/LEGAL GUARDIAN: ADDRESS: ______________________________________ CITY: __________________ STATE: ______ CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: ADDRESS: ______________________________________ CITY: __________________ STATE: ______ RESIDENTIAL PARENT/LEGAL GUARDIAN: ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ ZIP: ______________ ________________ ZIP: ______________ ZIP: ______________ ________________ ZIP: ______________ ZIP: ______________ __________________________________________________________________ __________________________________________________________________ _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com PARTICIPANT (PERSON ORDERED TO PROVIDE INSURANCE): ________________________________________________ PROVIDER OF INSURANCE IS: G Obligor G Obligor's Spouse _________________ G Other _________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ SOCIAL SECURITY NUMBER: ______________________________________ EMPLOYER: EMPLOYER ADDRESS: EMPLOYER PHONE: NAME(S) OF PLAN(S): ZIP: ______________ DATE OF BIRTH: _________________________ ______________________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________________________________________________________ G GROUP PLAN G PRIVATE PLAN ______________________________________________________________________________________ _______________________________________________________ ___________________________________________________________________________________________________________ INSURANCE IS UNDER: NAME(S) / ADDRESS(ES) OF PLAN ADMINISTRATOR(S): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ POLICY AND/OR GROUP NUMBER(S): ________________________________________________________________________ DESCRIPTION OF TYPE OF COVERAGE TO BE PROVIDED: _____________________________________________________ ___________________________________________________________________________________________________________ PARTICIPANT (PERSON ORDERED TO PROVIDE INSURANCE): _________________________________________________ PROVIDER OF INSURANCE IS: G Obligee G Obligee's Spouse ________________ SOCIAL SECURITY NUMBER: ______________________________________ EMPLOYER: EMPLOYER ADDRESS: EMPLOYER PHONE: NAME(S) OF PLAN(S): G Other ________________________ ZIP: ______________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ DATE OF BIRTH: _________________________ ______________________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________________________________________________________ G GROUP PLAN G PRIVATE PLAN ______________________________________________________________________________________ _______________________________________________________ ___________________________________________________________________________________________________________ INSURANCE IS UNDER: NAME(S) / ADDRESS(ES) OF PLAN ADMINISTRATOR(S): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ POLICY AND/OR GROUP NUMBER(S): ________________________________________________________________________ DESCRIPTION OF TYPE OF COVERAGE TO BE PROVIDED: _____________________________________________________ ___________________________________________________