JUDGMENT AND ORDER UPON STIPULATION FOR UNREIMBURSED HEALTH CARE EXPENSES

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1 JUDGMENT AND ORDER UPON STIPULATION FOR UNREIMBURSED HEALTH CARE EXPENSES Packet

2 IMPORTANT THIS PACKET IS IN NO WAY INTENDED TO SUBSTITUTE FOR THE ADVICE OF A PRIVATE ATTORNEY. IMPORTANT If either party is in the military, special rules may apply and it is strongly recommended that you seek the advice of an attorney. Private Counsel is Always Recommended for Legal Matters. The law allows any person to represent themselves in a legal action. However, filing an action with the court and representing yourself in the courtroom can be a complicated legal procedure and this packet does not attempt to address all the legal issues involved in bringing your matter before the court. This packet is created to help you access the legal system without the assistance of an attorney. When representing yourself, you are responsible for understanding the law that governs your case and for filing the proper legal documents. The laws and rules are set out in the Nevada Revised Statutes, the Rules of Civil Procedure, and the local rules governing the jurisdiction in which you are filing your documents. When you sign these documents and present them for filing with the court, it is assumed by the court that you have carefully read the documents, that you understand all the terms in the documents, that you agree with all the provisions in the documents, and that you are aware of all the consequences those provisions may produce. Before filling in any portion of the following document, read all the material included in this packet regarding custody, visitation, child support, and definitions of terms. THIS INFORMATION IS PROVIDED AS A COURTESY ONLY. THE COURT, SELF HELP CENTER, NON-PROFIT ORGANIZATION, OR LAW LIBRARY THAT MAY PROVIDE THIS INFORMATION SHALL NOT BE LIABLE FOR ERRORS CONTAINED HEREIN OR FOR DIRECT, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES IN CONNECTION WITH THE FURNISHING OF THIS MATERIAL.

3 Filling Out and Filing the Judgment and Order Upon Stipulation For Unreimbursed Health Care Expenses When filling out the document, be sure to print neatly, use black or blue ink and do not use white-out on any portion of the document. If you make a mistake, just draw a line through it and correct it. The file clerk will not take any documents with white-out on them. Page 1 On lines 1-7, each party must print his or her own name, address and telephone number. On lines 12-15, fill in the heading exactly as it appears on the other documents filed in this matter. On lines 24-28, fill in the names and birth dates of the children in this matter. Page 2 On line 2, fill in the amount owed by the Respondent to the Petitioner. On lines 3-4, state the dates that the sum on line 2 covers. For instance, from January 1, 1999 through January 1, Be sure there are specific dates in these two spaces. On line 4, print the amount the Respondent is going to pay towards the amount stated on line 2, each month. On line 5, state the date the first payment is due. Page 3 Complete and sign the form. REV 10/2009 1

4 Copying and Filing the Document You are responsible for the proper copying and filing of the documents. It is better if you make the copies before bringing them to be filed in. If the filing clerk s office makes copies for you they must charge $0.50 per page for copies. You will need at least two copies of the documents in addition to the original. Take the original documents and the copies to the filing clerk s office located on the first floor of the courthouse at 75 Court Street, Reno, NV. The filing clerk will keep the original document and return the file stamped copies to you. The file clerk will now transfer the whole file to the judge for review and signature on the order. It is advised that you each include a self addressed, stamped envelope when you file your Stipulation with the file clerk s office so you can be assured of receiving a copy of the file stamped Order after the judge has signed it. If you do not receive a copy of the signed Order Affirming Stipulation within ten (10) days after filing it with the clerk s office, you may track the status of your documents. To track the status of your Order, contact the clerk s office at (775) If the Court needs more information than you have provided in the Stipulation, the Court may mail you a letter of deficiency stating what is needed to complete the Stipulation, or, the Court may set a hearing. In either case, it will be your responsibility to follow-up to complete the necessary paperwork to get your Stipulation affirmed. REV 10/2009 2

5 IMPORTANT BEFORE YOU START READ ALL INSTRUCTIONS CAREFULLY Do NOT use Wite-Out or other correction fluid/tape on the documents. The Filing Office will not accept documents with Wite-Out or other correction fluid/tape on them. Use Black Ink PRINT all information neatly REV 7/2010 AA

6 Code: 3980 Name: Address: Telephone: Name: Address: Telephone: Self-Represented Litigants IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA, Petitioner, vs., Respondent. / IN AND FOR THE COUNTY OF WASHOE Case No. Dept. No. JUDGMENT AND ORDER UPON STIPULATION FOR UNREIMBURSED HEALTH CARE EXPENSES The above-named parties hereby stipulate to the entry of an Order as follows: 1. Respondent is the parent of: NAME OF CHILD(REN) DATE OF BIRTH REV 9/2009 1

7 A judgment is to be entered against the Respondent for arrears in Unreimbursed health care expenses for the minor child(ren) in the amount of $_, said amount representing those sums due and owing from through and the Respondent shall pay $ per month to retire the judgment beginning. Said payment shall be made in addition to the child support payment. 3. No interest shall accrue on the arrearage so long as Respondent remains current on monthly payments. Should Respondent become thirty (30) days delinquent, or, should a pattern of over ten (10) days delinquency in payments develop without stipulation and acceptance by the Petitioner, Pursuant to NRS 125B.140, as amended, interest upon the arrearage shall accrue at a rate established pursuant to NRS , from the time each amount became due. 4. All property is subject to actions for collection including, but not limited to, withholding of wages, garnishment, liens, and the attachment of federal income tax refunds. 5. All payments must be made payable as follows: In accordance with Nevada Revised Statue and federal law, all Nevada child support payments currently paid to a Nevada child support agency must be sent to: STATE COLLECTION AND DISBURSEMENT UNIT (ScaDU) PO BOX LAS VEGAS, NV PLEASE NOTE: PAYMENTS MUST BE BY MONEY ORDER OR CASHIER CHECK AND PAYABLE TO ScaDU The following information must be included with each payment: 1. Name (first, middle, last) of person responsible for child support 2. Social Security Number of person responsible for child support 3. Name of custodian (first and last name of person receiving child support) 4. Child support case number If you have any questions regarding where to send your child support payments, please call your local District Attorney Family Support Division at (775) REV 9/2009 2

8 NOTICE: NO CREDIT WILL BE GIVEN FOR PAYMENTS PAID DIRECTLY TO THE PETITIONER. The Respondent is responsible for notifying the District Attorney s Office, Family Support Division, in writing, of any change of address, change of employment, change of custody, or entry of any other order relative to child support, within five (5) days of such change. This document does not contain the Social Security number of any person. We declare, under penalty of perjury under the law of the State of Nevada, that the foregoing is true and correct. Dated: (Signature) ORDER AND JUDGMENT Dated: (Signature) Based upon the above Stipulation of the parties in this action; and, The Court, being fully advised of the facts and circumstances in this matter, IT IS HEREBY ORDERED that the Stipulation is affirmed and Judgment is hereby entered against Respondent in the amount of $. IT IS FURTHER ORDERED that the Respondent shall satisfy the Judgment in the manner agreed upon, and stated above. DATE: DISTRICT JUDGE REV 9/2009 3