This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts.

For Court Use Only

STATE OF ILLINOIS,
ORDER FOR SUPPORT
CIRCUIT COURT
 Initial
COUNTY  Modification
 Enforcement
Instructions
Directly above, enter
the county where you
filed this case.
Enter the full name of Petitioner (First, middle, last name)
Petitioner,
Respondent, and the v.
case number the IV-D Case Number
Circuit Clerk gave
this case.
Enter the IV-D case
number if you know Respondent (First, middle, last name) Case Number
it.

• DO NOT fill out the rest of this form unless the judge tells you complete it.
NOTE:
• You MUST BRING the social security numbers of both Petitioner and Respondent to the court hearing.

THE COURT FINDS:

 1.  Petitioner  Respondent must pay support.
The person paying support is called “Obligor” in this Order. The Obligor is:
The person receiving support is called “Obligee” in this Order. The Obligee is:
 2. The children covered by this Order are:

 3. The combined gross income  does  does not exceed the uppermost levels of the schedule of
basic support obligations.
 4. The net income of Obligor is: $ per calculated by
 the standardized tax amount.
 the individualized tax amount.
 the agreement of the parties.
 5. The net income of Obligee is: $ per calculated by
 the standardized tax amount.
 the individualized tax amount.
 the agreement of the parties.
 6. The adjusted net income for Obligor is: $ per .
 7. The adjusted net income for Obligee is: $ per .
 8. The Basic Combined Support Obligation $ per .
 9. Obligor’s income is at or below 75% of the Federal Poverty Guidelines for a family of 1 person. Child
support is capped at $40 per month per child up to a maximum of $120 per month.
 10. Obligor receives only means tested assistance or cannot work due to a medically proven disability,
incarceration or institutionalization.
 11. Shared physical care: Each parent exercises 146 or more overnights per year. Basic Child Support
Obligation is: $ per (multiply amount in paragraph 8 x 1.5).
 12. Split care: Each of the parents has physical care of at least one, but not all of the children.

DV-CSO 129.4 Page 1 of 5 (02/24)

 Enter the Case Number given by the Circuit Clerk:_________________________________

 13. The amount of child support arrearage is: $ as of

plus an interest amount of: $ Date
 14. The amount of maintenance arrearage is: $ as of
plus an interest amount of: $ Date
 15. The amount of retroactive child support is: $ from to
Date Date
 16. The amount of retroactive maintenance is: $ from to
Date Date
 17. The amount of child support cannot be stated only in a dollar amount because some or all of the net income
of Obligor is uncertain as to source, time of payment, or amount.

IT IS ORDERED:

A. That Obligor will pay:

 1. Maintenance  Yes  No
a. The current maintenance payment is: $
b. The maintenance arrearage/retroactive payment is: $
c. The total maintenance payment is: $
d. Maintenance is to be paid:
 Once a week  Once every other week
 Once a month  Twice a month on: and .
Date Date
e. Maintenance payments begin .
Date
f. This maintenance order ends on: .
Date

 2. Child Support  Yes  No

a. The current child support payment is: $
b. The child support arrearage/retroactive payment is: $
c. The total child support payment is: $
d. Child support is to be paid:
 Once a week  Once every other week
 Once a month  Twice a month on: and .
Date Date
e. Child support payments begin on: .
Date
f. Obligor must also pay: % of their .
Type of Additional Income
This must be paid as follows:
Obligor must also give  Obligee and/or  the Clerk of the Court proof of their
within 7 days of receiving the income.
Type of Additional Income

 3. Other Support Orders:

B. Payment of Maintenance and Child Support:

 1. An Income Withholding for Support may immediately be served on Obligor’s employer. Until the Income
Withholding for Support takes effect Obligor is required to pay directly to the State Disbursement Unit.

DV-CSO 129.4 Page 2 of 5 (02/24)

 Enter the Case Number given by the Circuit Clerk:_________________________________
• Payments by Obligor or the employer must be made payable to: STATE DISBURSEMENT UNIT and
sent to: P.O. Box 5400, Carol Stream, IL 60197-5400.
• Payments must include: 1) the case number, 2) the name of the county of the Court issuing this Order for
Support, and 3) Obligor’s name and social security number.
• A new court Order is not necessary to serve an Income Withholding for Support on any future employer of
Obligor.
 2. Obligor will make payments:
 Directly to the State Disbursement Unit according to the schedule in Section A. Payments by Obligor
must be made payable to the STATE DISBURSEMENT UNIT and sent to: P.O. Box 5400, Carol Stream,
IL 60197-5400.
 Directly to Obligee as the parties have agreed according to the schedule in Section A. If Obligor falls
behind in payments, an Income Withholding for Support may be prepared and served on Obligor’s
employer. Obligor will then have to make payments to the State Disbursement Unit as stated in Section
B1.
 3. Obligor must also pay a $36 per year child support collection fee. This fee is not maintenance or child
support and cannot be subtracted from the support to be paid. This fee must be paid directly to the Circuit
Clerk of the county issuing this Order for Support.

C. Payment of Maintenance Only:

 1. Obligor will make payments
 Directly to Obligee
 Directly to the Circuit Clerk of this county
 2. If payments are made to the Circuit Clerk, Obligor must also pay a $36.00 per year support collection fee.
This is not maintenance and cannot be subtracted from the support to be paid. This fee must be paid directly to
the Circuit Clerk of the county issuing this order.

D. Delinquency (maintenance or child support):

 1. Delinquency Payments
If Obligor is delinquent in making a support payment after this Order for Support is entered, Obligor must
a. Continue to make current maintenance and child support payments, AND
b. Pay the sum of:
$ for child support per payment period ordered in Section A2d, PLUS
$ for maintenance per payment period ordered in Section A1d, until the delinquent
amount is paid in full.
A maintenance or child support payment, or part of a payment, that is due and remains unpaid for 30 days
or more will accrue interest at the rate of 9% each year.

E. Child Support Termination:

1. This child support order ends on: unless changed by a written order of the court.
Date
2. Unpaid Child Support at Termination
If Obligor owes an arrearage or delinquency on the termination date that is equal to at least one month’s
support payment, Obligor must continue to make payments. The payment amount must be the same
as the amount Obligor was ordered to pay in Section A2a.

F. Health Insurance:
 1. Decision Reserved
 2. a.  Obligor  Obligee will provide health insurance for the children by:
 Enrolling them in health insurance coverage available through their employer.
 Providing other insurance  dental  orthodontic  vision
 prescription medication  other: .
DV-CSO 129.4 Page 3 of 5 (02/24)
 Enter the Case Number given by the Circuit Clerk:_________________________________
 Giving a copy of the insurance policy and the insurance card to the other parent within 45 days
of the date of this Order.
b. The cost of the insurance will be paid by:
 Obligor: %  Obligee: %
NOTE: Health insurance premiums are added to the Basic Support Obligation and then divided pro rata.
If Obligor’s paying the premium, the amount that is Obligee’s responsibility must be subtracted from
Obligor’s support obligation. If Obligee is paying the premium, Obligor's support obligation shall be
increased by Obligor's share of the premium.
c. The cost of healthcare expenses not covered by insurance will be paid by:
 Obligor and Obligee equally
 Obligor: %  Obligee: %

G. Child Care Expenses:

 1. Decision Reserved
 2. a.  Child care expenses are reasonably necessary for  Petitioner  Respondent
to be employed, attend educational or vocational training to improve employment opportunities, or to
look for work.
b.  The cost of child care expenses shall be paid by:  Obligor %
 Obligee %
c.  Payment shall be made directly to:  Obligee  Child care provider

H. School and Extra-Curricular Expenses:

 1. Decision Reserved
 2. a.  School and extra-curricular expenses covered by this Order

b.  The cost of extra-curricular expenses shall be paid  Obligor %

Obligee %

I. Other Orders:
The Support Information Sheet filed in this case shall be impounded by the Circuit Clerk in order to protect the
confidential information contained in it.
1. Notice of Address Change
Each party must tell the other of any change in address within 5 days of the change.
This does not apply to the following parties  Petitioner  Respondent because the physical,
mental or emotional health of that party and/or the minor children would be seriously endangered by
disclosure of that party’s address.
Obligor must give written notice of any change in home address or mailing address within 7 days of the
change to:
• The Circuit Clerk of the county issuing this Order for Support, AND
• The Illinois Department of Healthcare and Family Services, BUT ONLY if a party is receiving child and
spouse services under Article X of the Illinois Public Aid Code.
2. Notice of Change to Other Information
Obligor must give written notice of any change to personal contact information within 7 days of the change,
including:
• New telephone number; AND
• If Obligor can get health insurance through the employer or other group coverage and if so list:
the policy name, the policy number, and the names of persons covered under the policy.
Obligor must give the written notice to:
• The Circuit Clerk of the county issuing this Order for Support, AND
• The Illinois Department of Healthcare and Family Services, BUT ONLY if a party is receiving child and
spouse services under Article X of the Illinois Public Aid Code.
DV-CSO 129.4 Page 4 of 5 (02/24)
 Enter the Case Number given by the Circuit Clerk:_________________________________

3. Notice of Change to Employment

Obligor must give written notice of any employment change within 7 days of the change, including:
• If Obligor lost a job, OR
• If Obligor got a new job, AND
• The name, address, and phone number of a new employer.
Obligor must give the written notice to:
• Obligee,
• The Circuit Clerk of the county issuing this Order for Support, AND
• The Illinois Department of Healthcare and Family Services, BUT ONLY if a party is receiving child and
spouse services under Article X of the Illinois Public Aid Code.
4. Notice of Change to Support Information Sheet
Obligor and Obligee must give written notice of any change to the information on the Support Information
Sheet filed with this case within 5 days of the change. Obligor and Obligee must give the written notice to
the Circuit Clerk of the county issuing this Order for Support.
5. Proof of Continuing Insurance Coverage
If Obligor has received an adjustment to their support obligation because of the payment of insurance
premiums, Obligor must annually submit proof of continuing insurance coverage of the children to the
Division of Child Support Enforcement of the Department of Human Services and to Obligee.

J. Additional Conditions or Findings:

 1. The child support payment amount is different than the amount required by child support guidelines
because:
a.  extraordinary medical expenditures necessary to preserve the life or health of a party or a child
of either or both of the parties.
b.  additional expenses incurred for a child covered by this support order who has special medical,
physical or developmental needs.
c.  the amount required by child support guidelines is: $
d.  Other:

 2.  Other:

 3. A child support calculation prepared by using the Illinois Department of Healthcare and Family Services
estimator is attached:  Yes  No
 4. The child support calculation was prepared by  Petitioner  Respondent  Judge

K. Other:

ENTERED:
DO NOT complete
this section. The
judge will complete it.
Judge Date

A JUDGE CAN FIND YOU IN CONTEMPT OF COURT IF YOU FAIL TO OBEY ANY PART OF THIS ORDER.

DV-CSO 129.4 Page 5 of 5 (02/24)

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