DONALD R. HOFFMAN (#07332) 112 West 7th Street - Garden Suite Topeka, Kansas 66603 Tel: (785) 233-5887 Fax: (785) 233-2173 Attorney for Petitioner IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 2 In the Matter of the Marriage of HAL RICHARDSON and Case No. 96 D 217 CLAUDINE DOMBROWSKI AGREED ORDER NOW on this of day of _ Ager, 2001, comes on for approval of the Court, the within agreement of the parties regarding child support. Petitioner appears through counsel, Donald R. Hoffman. Respondent appears through counsel, Leonard M. Robinson, ‘The Court after reviewing the file and being fully advised, finds: 1, Respondent shall pay Petitioner $225.00 per month child support commencing August 1, 2001, 2. Petitioner shall continue to maintain the present health insurance All unreimbursed medical expenses for the parties’ minor child shall be paid proportionately by the parties in accordance with their respective incomes as set forth in the child support worksheet “A”, Petitioner 28.54 % and Respondent 71.4%%. (See attachment) 3. Petitioner is entitled to the tax exemption for the minor child, Rikki A. Dombrowski, DOB: 12-12-94, for the year 2001 and the years thereafter. 4. The attached mandatory supplemental orders required by Shawnee County District Court Rule 3.401 are hereby incorporated herein by reference. 5. Thatall prior orders not modified herein shall remain in full force and effect until further order of this Court.IT IS SO ORDERED. [GLI D Alb — DISTRICT COURT JUDGE 112 West 7th Street -Garden Suite Topeka, Kansas 66603 Tel: (785) 233-5887 Fax: (785) 233-2173 Attomey for Petitioner eo LEONARD M. ROBINSON 201 N.W. Hwy 24, Ste. 140 P.O. Box 8138 Topeka, Kansas 66608-0138 (785) 233-7001 Attorney for RespondentMANDATORY SUPPLEMENTAL ORDERS The following mandatory supplemental orders pertaining to enforcement of child support are incorporated in the foregoing order and are incorporated as a part thereof pursuant of Shawnee ‘County District Court Rule #3.401: IT IS FURTHER ORDERED that all child support payments shall be paid to the Kansas Payment Center, P.O. Box 758599, Topeka, Kansas 66675-8599 unless otherwise ordered by the Court. Any payments of child support not made in accordance with this provision shall be presumptively disallowed. Any payments made payable to the obligee may be endorsed and cashed by the Kansas Payment Center. IT IS FURTHER ORDERED that all new or modified non-IV-D support orders must be accompanied by a support order information sheet available in the office of the clerk of the District Court. IT IS FURTHER ORDERED that the Office of SRS or their contracting agent for IV- D cases, or the District Court Trustee for private cases shall monitor and enforce the payments of support ordered herein and may pursue on behalf of any child al civil remedies available to the obligee to enforce payments of child support. IT IS FURTHER ORDERED that each party shall inform the Clerk of the District Court, the Kansas Payment Center and SRS for IV-D cases, or the District Court Trustee for private cases in writing of any changes of name, residence, and employer including business address within seven (7) days after such change. IT IS FURTHER ORDERED that withholding of income to enforce this order of support or modification shall take effect thereto without further notice pursuant to K.S.A. 23-4, 107, and any amendments thereto. IT IS FURTHER ORDERED that the amount of child support payable per month in this case is $225.00 current, commencing August 1, 2001, and due on or before the Ist day of each month. The payments in this case are to be paid monthly. IT IS FURTHER ORDERED that the following information be provided each time an Order is entered: Petitioner Home Phone: Home Phone: (785) 379-5254 (785) 539-5583, Home Address: Home Address: 1727 Shawnee Heights Rd. PO Box 984 Topeka, Ks 66542 Manhattan, KS 66505 Employer Name: Employer Name: Topeka Vinyl Top Center Not employed Business Phone: Business Phone: (785) 266-4114 N/A Soc. Sec. No.: Soc. Sec. No. 510-70-4518 511-74-964507/24/2681 14:37 785-233-7061 DAVID MILLER OR LMR Pace 02 i Copy IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS Dwvialon Inthe Matter of the Mariage of HAL RICHARDSON Case No 96-0-217 ang Division 2 (CLAUDINE DOMBROWSK\ CHILD SUPPORT WORKSHEET {SUBMITTED BY MOTHER) MOTHER FATHER TOTAL (GROSS ANNUAL INCOMES 10602 zeae 37.200 |A INGOME COMPUTATION - WAGE EARNER 1. Domeste rots income (Wage. interest ot) 81 2219 310 8 INGOME COMPUTATION - SELF-EMPLOYED + Sev-srmployment Gross income ° ° 2 Reasonable Business Expenses (ne SE tax ° ° 4. Domestic Gross income (SettEmployed) ° ADJUSTMENTS TO DOMESTIC GROSS INCOME 1. Goes teome (Tota Monthy) ost 2219 Cost of Living Adjustment ° ° 2 Otter Cour-Ordered Chid Suppor Paid ° ° 5. Maintenance Rees (Pag) nthe case ° ° 4 Manienance Rect (Pai) oer cates ° ° 5. Child Support Income 7 ZEW 70 D. COMPUTATION OF CHILD SUPPORT 1. Child Suppor Income 0s 2219 © at0 2. Proportnate Shares of Combined income 226% Tame 100% 2 Base Chit Support Obigaton Age of etre Ce) Numb: per age 7 3 o ‘Amount potent 35 ° ° TOTALS s o o 37507/24/2001 14:37 785-233-7061 Page 2 1D. COMPUTATION OF CHILD SUPPORT (Cont) 4, Heath and Dental Insurance Prerium 6, Wotk-Relates Chid Care Costs Less Child Cave Tax Crest in, Kansas credit) 65, Parents Total Chid Support Obligation 7. Each Parent's Child Support Obigation 8, Adjustment for insurance & Child Care 9, Net Parental Child Support Obrigation (Percentage of Parent's Gross income) E, CHILD SUPPORT ADJUSTMENTS Applicable yes No. Category Long Dist. Visitation Costs Visitation Adjustment noome Tax Considerations. Special Needs Agreement Past Minonty Overall Financial Condition PELER Total Adjustments . ADJUSTED CHILD SUPPORT SUMMARY (Deviations from rebuttable presumption amount) 1. Basic Parental Chid Suppott Obligation 2. Total Child Support Adjustments 3. Adjusted Subtotal Child Support Payabie by Mother Child Support Enforcement Foe Allowance Total Amount Payable Prepares by ‘Leonard M. Robineon # PO Box 6138) “Topeka KS 66808-0138 785 233-7001 [Attorney for Respondent Administrative Order No. 128 DAVID MILLER OR LR PAGE 93 f ws = 0 ay | ee coe! (2A) 4 ; Date: -30-o0f on 32000 Veto 121 Copyright 2000 Brady StareKansas Payment Center ~ Child Support Order Information Sheet Purpose: Federal law requires Kansas (0 process child support through a single location in tne slate. To insure that processing of child suppoxt payments is not delayed, the Kansas Payment Center listed on the form below. just have all information Who submits the completed form: The payee’s attorney shall file the completed form along with the Journal Entry with the Clerk of the District Court per Kansas Supreme Court Administrative Order No, 154, Case Number: You must give the full, acevrate court order number, or payments may be delayed. The case number may be copied from the child support order. The case number format is as follows: County - Year - Case Type - Case Number Example: WY00D 000123. (WY) (00) (D) (000123) Please call your local clerk of the district court if you need additional information to complete this form, Additional copies may be made as necessary, PLEASE print or type all information. Case Number:_SN_96 D 217 ‘Check if applicable: ‘Cheek one: Gi New caselorder | SF Court ‘Trustee case ©) Modified order Interstate: Filestamp Date of Order (above): | = | _ ee | (Obligation Information Support Frequency Start | Payment Frequency Codes Amount Code Date (W) Weekly | @) Biweerly | Current Child Support duc: $225.00] $225.00 Mw Baten | (M)_ Monthly | | (SM) Semi-Monthly | Current Maintenance (Alimony) due: | $___ —— |] @ Quanery : (A) Annually Other Support due: so ———— | GA) Semi-Annuatly 1) Lumpgum ‘ c eS" 33. ee ee 2a 7 Zi B gees | —_— . See o Pete sl Been eee v oes ne se eo GF j 2 S Information about the PAYING Parent NAME (First, Middle Initial, Last) CLAUDINE DOMBROWSKI as Social Seourity Number. Date of Birth Phone: 5 51-74-9645 04/10/65 7 __|__ 785 539-5583 Address City: State Zip: PO Box 984 Manhattan KS 66505 9/14/00NAME (First, Middle Init HAL RICHARDSON Last) Information about the Parent or Person RECEIVING support Social Security Number: Date of Birth: Phore: 510-70-4518 9-9-60 266-4114 Address: City: State: Zip: 1727 SHAWNEE HEIGHTS RD. TECUMSEH KANSAS 66542 Information about the Third Party Payee ~ NAME (rst, Middle Initial, Last) OA Social Security Number: Date of Birth: Phone! Address: State: Zip: Information about CHILD(REN) covered by this support order NAME (First and Last) fal Security Number Date of Birth: 1. RIKKI _ | 513-11-4344 2212-94 2 3 | 14 2 {5 s | - 1 a 8 9. i Completed By: - Date Print Name (and title):___DONALD_R. HOFFMAN. (#07332) _ a ‘Attorney for Petitioner ‘The completed form must be attached to the journal entry and filed with the Clerk of the District Court: 09/14/00