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					Petition to Modify Custody/Parentage Plan
                   and/or
            Child Support Order
              Questionnaire




Questionnaire
Do It Yourself Documents




www.doityourselfdocuments.com




Returning the Questionnaire:
Complete this questionnaire using a pen then fax, mail or drop it off at our
Federal Way or Tacoma office. Presently, our Renton office is available by
appointment only; we do not keep it staffed. If you plan on using our Renton
office please return the questionnaire using our Federal Way office
information.

 Federal Way Office:                    Tacoma Office:

 Do It Yourself Documents               Do It Yourself Documents
 1819 South Commons                     2501 East D Street
 Federal Way, WA 98003                  Suites 107 & 110
                                        Tacoma, WA 98421
 FAX: (888) 377-2397
                                        FAX: (888) 377-2397
Process
        Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order




In order for us to process your paperwork, we will need you to complete this questionnaire. You
should save this questionnaire to your desktop or somewhere on your computer that you can
easily find. Once you complete the questionnaire you can return it by seeing the section above,
“Returning the Questionnaire”. Upon receipt of the fully completed questionnaire and payment,
your documents will be processed and sent to you within 24 hours with full instructions for
signing.

          Filing Fees:


If you file in the same court as the original case the filing fee is $56.00; otherwise, the filing fee for
all counties in Washington State is $250.

          In-Office Services:


If you live within driving distance of our office, you may opt to come to our office and sign all
documents at no additional costs. We will supply the notary and take care of all the filing for you
if you choose this option. A signing appointment usually takes 15 – 30 minutes and can usually be
scheduled within 24 hours of us receiving the completed questionnaire.

          Questions while completing this questionnaire:


If you have any questions while completing the questionnaire, please do not hesitate to contact
us, either through the chat located on any page of the website or by calling us.


Throughout this questionnaire, you will see sections as the one below this paragraph. They
are for you to add any additional information you think we should know regarding the section of
the questionnaire you are working on. Feel free to use them to add additional information or
leave us comments to help us improve on our questionnaire.
Additional info add here:




Toll Free: (866) 946-0325                  Page |2                           Fax: (888) 377-2397
       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order


Please select ONE of the following services:

Modification:
    1. ( ) Modification of an existing custody/parenting plan AND child support order; or
    2. ( ) Modification of an existing custody/parenting plan; or
    3. ( ) Modification of existing child support order
For a modification, we need a copy of the original order or plan that you are requesting a
modification of. You may email, fax, mail, or drop it off at our office along with this
questionnaire.

          Please select which county you will be filing in:


( ) Lincoln County – Available for all Washington residents. With this option you do not have
to appear in court; however, if the other party is not in agreement you may have to appear in
Court in Davenport, Washington.
( ) Other county, (must be the county the child(ren) reside in): ______________
NOTE: If the children reside in the same county as the original order or plan you should file in
the same court and the court cost for a modification is $36.00 vs. $220.00.

          How would you like us to return your documents?


(   ) Returned to you by Priority Mail
(   ) Returned by secure/encrypted email
(   ) Come into our office to sign - notary fees are included in price
    • ( ) Federal Way – Office
    • ( ) Tacoma - Office




Moving Party’s Information:
          The Moving Party is the parent requesting the modification and the
          other parent will be known as the Nonmoving Party:


First Name
Middle Name
Last Name
You are the child(ren)’s :      (   )Mother     (   )Father    (   )Other: ______________

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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Social Security Number
Driver’s License Number                                                   State
Telephone Number                   (        )
E-mail Address
Date of Birth mm/dd/yyyy
State of Birth
Are you in the military?           (     ) Yes (      ) No
Additional info add here:

           Moving Party’s Address:


Address
City
State
ZIP Code
County

           Moving Party’s Mailing Address:


Is street address different    (       ) Yes (       ) No
from mailing address?
Mailing Address
City




Nonmoving Party’s Information:
State
ZIP Code




           The nonmoving party is the other parent


First Name
Middle Name
Last Name
Nonmoving Party is the                  (       )Mother     (   )Father   (   )Other: ______________

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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



child(ren)’s :
Social Security Number
Driver’s License Number
Telephone Number                    (   )
E-mail Address                                                    State
Date of Birth mm/dd/yyyy
State of Birth
Additional info add here:

           Nonmoving Party’s Address:


Address
City
State
ZIP Code
County

           Nonmoving Party’s Mailing Address:


Is street address different    (   ) Yes (     ) No
from mailing address?
Mailing Address
City




Employment Information:
State
ZIP Code




           Moving Party’s (person requesting modification) Employment:


Name of Company
Address Line 1
Address Line 2
City

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        Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



State
ZIP Code
Telephone Number            (   )

           Nonmoving Party’s (other parent) Employment:


Name of Company
Address Line 1
Address Line 2
City
State




Modification of Parenting Plan and/or
ZIP Code




Child Support Order
Telephone Number            (   )




For the court to modify your parenting plan or child support order you will need to select one or
more of the following RCW Statutes that gives the court jurisdiction:
    1. Modification under RCW 26.09.260(1), (2)
    2. Modification under RCW 26.09.260 (4) or (8)
    3. Adjustments to Residential Provisions Under RCW 26.09.260(5)(a) and (b)
    4. Adjustments to Residential Provisions Under RCW 26.09.260(5)(c), (7), (9)
1. Modification under RCW 26.09.260(1), (2)
(     ) No (     ) Yes
   (1) “the court shall not modify a prior custody decree or a parenting plan unless it finds, upon
the basis of facts that have arisen since the prior decree or plan or that were unknown to the court
at the time of the prior decree or plan, that a substantial change has occurred in the
circumstances of the child or the nonmoving party and that the modification is in the best
interest of the child and is necessary to serve the best interests of the child.
    (2) In applying these standards, the court shall retain the residential schedule established by
the decree or parenting plan unless:
    (a) The parents agree to the modification;
    (b) The child has been integrated into the family of the petitioner with the consent of the other
parent in substantial deviation from the parenting plan;
    (c) The child's present environment is detrimental to the child's physical, mental, or emotional


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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



health and the harm likely to be caused by a change of environment is outweighed by the
advantage of a change to the child; or
   (d) The court has found the nonmoving parent in contempt of court at least twice within three
years because the parent failed to comply with the residential time provisions in the court-
ordered parenting plan, or the parent has been convicted of custodial interference in the first or
second degree under RCW 9A.40.060 or 9A.40.070.
Additional info add here:


2. Modification under RCW 26.09.260 (4) or (8)
(     ) No (    ) Yes
(4) The court may reduce or restrict contact between the child and the parent with whom the
child does not reside a majority of the time if it finds that the reduction or restriction would serve
and protect the best interests of the child using the criteria in RCW 26.09.191.
(8) If a parent with whom the child does not reside a majority of the time voluntarily fails to
exercise residential time for an extended period, that is, one year or longer, the court upon proper
motion may make adjustments to the parenting plan in keeping with the best interests of the
minor child.
(   ) The custody decree/parenting plan/residential schedule should be modified because the
reduction or restriction of the residential time for the person with whom the child does not reside a
majority of the time would serve and protect the best interests of the child using the criteria in
RCW 26.09.191, as described here: ______________

(    ) The custody decree/parenting plan/residential schedule should be adjusted because the
nonresidential party has voluntarily failed to exercise residential time for one year or more and the
adjustment is in the best interest of the children.
Additional info add here:


3. Adjustments to Residential Provisions Under RCW 26.09.260(5)(a)
and (b)
 (     ) No (    ) Yes
 (5) The court may order adjustments to the residential aspects of a parenting plan upon a
showing of a substantial change in circumstances of either parent or of the child, and without
consideration of the factors set forth in subsection (2) of this section, if the proposed modification
is only a minor modification in the residential schedule that does not change the residence the
child is scheduled to reside in the majority of the time and:
    (a) Does not exceed twenty-four full days in a calendar year; or
    (b) Is based on a change of residence of the parent with whom the child does not reside the
majority of the time or an involuntary change in work schedule by a parent which makes the
residential schedule in the parenting plan impractical to follow; or



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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Additional info add here:


4. Adjustments to Residential Provisions Under RCW 26.09.260(5)(c),
(7), (9)

(      ) No (    ) Yes
  (5) The court may order adjustments to the residential aspects of a parenting plan upon a
showing of a substantial change in circumstances of either parent or of the child, and without
consideration of the factors set forth in subsection (2) of this section, if the proposed modification
is only a minor modification in the residential schedule that does not change the residence the
child is scheduled to reside in the majority of the time and:
     (c) Does not result in a schedule that exceeds ninety overnights per year in total, if the court
finds that, at the time the petition for modification is filed, the decree of dissolution or parenting
plan does not provide reasonable time with the parent with whom the child does not reside a
majority of the time, and further, the court finds that it is in the best interests of the child to
increase residential time with the parent in excess of the residential time period in (a) of this
subsection. However, any motion under this subsection (5)(c) is subject to the factors established
in subsection (2) of this section if the party bringing the petition has previously been granted a
modification under this same subsection within twenty-four months of the current motion. Relief
granted under this section shall not be the sole basis for adjusting or modifying child support.
    (7) A parent with whom the child does not reside a majority of the time and whose residential
time with the child is subject to limitations pursuant to RCW 26.09.191 (2) or (3) may not seek
expansion of residential time under subsection (5)(c) of this section unless that parent
demonstrates a substantial change in circumstances specifically related to the basis for the
limitation.
    (9) A parent with whom the child does not reside a majority of the time who is required by the
existing parenting plan to complete evaluations, treatment, parenting, or other classes may not
seek expansion of residential time under subsection (5)(c) of this section unless that parent has
fully complied with such requirements.
Additional info add here:


This section only applies to a person with whom the child does not reside a majority of the
time who is seeking to increase residential time.
       2.11.1 Parent subject to limitations under RCW 26.09.191(2) or (3)
       (     ) The residential time of ______________ [Name] is not subject to limitations.
       (     ) The residential time of ______________ [Name] is subject to limitations. This
       parent demonstrates a substantial change in circumstances specifically related to the basis
       for the limitation.
       2.11.2 Parent Required to Complete Evaluations, Treatment, Parenting or Other
       Classes
       (     ) ______________ [Name] is not required under the existing Parenting
       Plan/Residential Schedule to complete evaluations, treatment, parenting or other classes.


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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



       (     ) ______________ [Name], is required by the existing Parenting Plan/Residential
       Schedule to complete evaluations, treatment, parenting or other classes. This parent has
       fully complied with such requirements as described here: ______________
       2.11.3 Adjustment to Residential Provision Under RCW 26.09.260(5)(c)
       (     ) The Custody Decree/Parenting Plan/Residential Schedule should be adjusted
       because a substantial change in circumstances of ______________ [Parent’s Name] or
       ______________ [Child(ren)’s Name(s)] has occurred. The proposed modification to the
       Custody Decree/Parenting Plan/Residential Schedule is in the best interest of the
       children. It is a minor modification in the residential schedule that does not change the
       residence the children are scheduled to reside in the majority of the time. The increase is
       more than 24 full days but less than 90 overnights per year total. The Custody
       Decree/Parenting Plan/Residential Schedule does not provide reasonable time with the
       nonprimary residential party.

Adjustments to Nonresidential Provisions under RCW 26.09.260(10)
       The following nonresidential provisions of the parenting plan should be adjusted because
       there is a substantial change of circumstances of either party or of the children and the
       adjustment is in the best interest of the children:
                (    ) Dispute resolution.
                (    ) Decision making.
                (    ) Transportation arrangements.
                (    ) Other: ______________
Additional info add here:


YOU MUST ANSWER THE FOLLOWING QUESTIONS:
The requested modification or adjustment of the custody decree/parenting plan/residential
schedule is based upon the following substantial change in circumstance: ______________

       A. Military Status of party not petitioning the court. (Other Parent or nonmoving party):
                  (    ) is not a service member;
                  (    ) is on active duty in the U.S. armed forces (excluding National Guard
                      and reserves);
                  (    ) is on active duty and is a National Guard member or a Reservist
                      residing in Washington.
                  (    ) is not on active duty in the U.S. armed forces (excluding National
                      Guard and reserves);
                  (    ) is not on active duty and is a National Guard member or a Reservist
                      residing in Washington;
                  (    ) I am unable to determine whether the nonmoving party is or is not on
                      active duty in the U.S. armed forces;

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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



                    (      ) I am unable to determine whether the nonmoving party (other parent)
                         is or is not on active duty as a National Guard member or a Reservist
                         residing in Washington.
               B.   Factual basis:
                     (     ) See the attached Defense Man Power Data Center Report obtained
                         from https://www.dmdc.osd.mil/scra/owa/home.
                     (     ) Other factual basis: ______________
               C.   (     ) As indicated above, the nonmoving party (other parent) is on active
                         duty and (check all that apply):
                         (     ) The nonmoving party (other parent) is represented by an attorney.
                         (     ) The court has appointed an attorney to represent the nonmoving
                                          party.
                         (     ) A stay of these proceedings (      ) has (  ) has not been entered
                                          by the court.
       2.15.2 A.    If nonmoving party (other parent) is a Dependent of a service member select
                     status:
                     (     ) is a dependent of a resident of Washington who is on active duty and is
                         a National Guard member or a Reservist;
                     (     ) is not a dependent of a resident of Washington who is on active duty
                         and is a National Guard member or a Reservist;
                     (     ) I am unable to determine whether the nonmoving party is a dependent
                         of a resident of Washington who is on active duty and is a National Guard
                         member or a Reservist.
               B.   Factual basis:
                     (     ) The nonmoving party failed to respond to a notice to him or her as a
                         dependent of a person in Military Service that was (     ) served on (    )
                         mailed by first class mail on ____/____/201__ [Date], therefore he or she
                         should be presumed not a dependent of a resident of Washington who is
                         on active duty and is a National Guard member or a Reservist.
                     (     ) Other factual basis: ______________
               C.    (     ) As indicated above, the nonmoving party is a dependent of a resident of
                         Washington who is on active duty and is a National Guard member or a
                         Reservist and (check all that apply):
                         (     ) The nonmoving party is represented by an attorney.
                         (     ) The court has appointed an attorney to represent the nonmoving
                                  party.
                         (     ) A stay of these proceedings (       ) has (   ) has not been entered
                                  by the court.




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RESTRAINING ORDERS/PROTECTIVE
        Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order




ORDERS
(   ) Yes (      ) No    Are there any protective orders or restraining orders filed by either party
                         against the other?
(   )                    The MOTHER has one against the FATHER.
(   )                    The FATHER has one against the MOTHER.
           County
              State




Information regarding Children from
          Case No.




both Mother and Father
Additional info add here:




          Dependent Children:


The following dependent children are considered children of both the MOTHER and FATHER
and must be listed in this section: (1) children born or conceived during a marriage; (2) children
adopted by one or both of you during a marriage; and (3) children born outside of a marriage if
the Moving Party and Nonmoving Party are the parents of the children.

          1st Child:


First Name
Middle Name
Last Name
Social Security Number
Date of Birth mm/dd/yyyy
Select which parent should be awarded the              (   ) Mother          (    ) Father
income tax exemption for this child each year:
Child’s home address, if left empty we assume the child lives with parent selected for tax


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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



deduction.
Address Line 1
Address Line 2
City
State
ZIP Code
County
If, during the past five years, this child has lived (1) outside the State of Washington or (2) with
any person other than you or nonmoving party, list each city and state and the names and present
addresses of the persons with whom the child lived at that time:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
Dates resided at prior                -
address:
If any persons other than you or nonmoving
party have physical custody of this child or
claim to have custody or visitation rights with
respect to this child, list them here
Describe any legal action in any state which has
happened in the past or which is going on now
concerning    the     custody,    paternity   or
dependency of this child
Additional info add here:

           2nd Child:


First Name
Middle Name
Last Name
Social Security Number
Date of Birth mm/dd/yyyy



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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Select which parent should be awarded the                (   ) Mother        (    ) Father
income tax exemption for this child each year:
Child’s home address, if left empty we assume the child lives with parent selected for tax
deduction.
Address Line 1
Address Line 2
City
State
ZIP Code
County
If, during the past five years, this child has lived (1) outside the State of Washington or (2) with
any person other than you or nonmoving party, list each city and state and the names and present
addresses of the persons with whom the child lived at that time:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
Dates resided at prior                -
address:
If any persons other than you or nonmoving
party have physical custody of this child or
claim to have custody or visitation rights with
respect to this child, list them here
Describe any legal action in any state which has
happened in the past or which is going on now
concerning    the     custody,    paternity   or
dependency of this child
Additional info add here:

           3rd Child:


First Name
Middle Name
Last Name


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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Social Security Number
Date of Birth mm/dd/yyyy
Select which parent should be awarded the                (   ) Mother        (    ) Father
income tax exemption for this child each year:
Child’s home address, if left empty we assume the child lives with parent selected for tax
deduction.
Address Line 1
Address Line 2
City
State
ZIP Code
County
If, during the past five years, this child has lived (1) outside the State of Washington or (2) with
any person other than you or nonmoving party, list each city and state and the names and present
addresses of the persons with whom the child lived at that time:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
Dates resided at prior                -
address:
If any persons other than you or nonmoving
party have physical custody of this child or
claim to have custody or visitation rights with
respect to this child, list them here
Describe any legal action in any state which has
happened in the past or which is going on now
concerning    the     custody,    paternity   or
dependency of this child
Additional info add here:

           4th Child:


First Name


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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Middle Name
Last Name
Social Security Number
Date of Birth mm/dd/yyyy
Select which parent should be awarded the                (   ) Mother        (    ) Father
income tax exemption for this child each year:
Child’s home address, if left empty we assume the child lives with parent selected for tax
deduction.
Address Line 1
Address Line 2
City
State
ZIP Code
County
If, during the past five years, this child has lived (1) outside the State of Washington or (2) with
any person other than you or nonmoving party, list each city and state and the names and present
addresses of the persons with whom the child lived at that time:
Name
Address Line 1
Address Line 2
City
State
ZIP Code
Dates resided at prior                -
address:
If any persons other than you or nonmoving
party have physical custody of this child or
claim to have custody or visitation rights with
respect to this child, list them here
Describe any legal action in any state which has
happened in the past or which is going on now
concerning    the     custody,    paternity   or
dependency of this child
Additional info add here:

           Residential Schedule for Children:


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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



The following dependent children are considered children of MOTHER and FATHER and must be
listed in this section: (1) children born or conceived during a marriage; (2) children adopted by
one or both of you during a marriage; and (3) children born outside of a marriage if the Moving
Party and Nonmoving Party are the parents of the children.
The "Parenting Act" requires that the residential schedule in your papers specify where your
children will be on every day of the year. You can achieve this by putting some specific entry in
each part of this section. The judge will not accept phrases like "reasonable visitation" or "liberal
visitation," and you CANNOT leave the decision to be made later with phrases such as "whenever
he/she want to see the child" or "whenever the child wants" or "as agreed."

Are you changing any holiday or special occasion visitation from the original Parenting Plan:
(    ) No, if( ) Yes, please complete the following section:
                   Mother Every       Father Every       Mother-Even        Father-Even Mother-
                   Year               Year               Father-Odd         Odd Years
                                                         Years
New Years Day
ML King Day
President’s Day
Memorial Day
Fourth of July
Labor Day
Veteran’s Day
Thanksgiving
Day
Christmas Eve
Christmas Day
Mother’s
Birthday
Mother’s Day
Father’s Day
Father’s
Birthday
Child’s Birthday
Other:
Other:
Other:
Other:

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         Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



Other:
These special occasions begin at 9:00 a.m. on the special day and end at 9:00 a.m. the following
day unless you inform us of different times. ______________
 Additional info add here:

Please complete the following section as to what you want changed in the existing
parenting plan:

1. Prior to enrollment in school, primary residence shall be with:
                                    PRE-SCHOOL SCHEDULE
Mother (      )              Father (    )                 Children already in school (        )
Additional info add here:
2. Prior to enrollment in school, the children will reside with the other parent at the following
times
  (      )   The second and fourth full weekends of each month beginning at 6:00 p.m. on Friday
             and ending at 6:00 p.m. on Sunday.
  (      )   Other: ______________
 Additional info add here:


                                    SCHOOL YEAR SCHEDULE
1. During the children's school year, they shall reside   Mother (     )      Father (     )
primarily with
2. The children will reside with the other parent at the following times during the school year:
  (      )   The second and fourth full weekends of each month beginning at 6:00 p.m. on Friday
             and ending at 6:00 p.m. on Sunday.
  (      )   Other: ______________
  (      )   Other: ______________
Additional info add here:


                         WINTER (CHRISTMAS) VACATION SCHEDULE
1. During the children's Winter Vacation each year,       Mother (     )      Father (     )
they shall reside primarily with:
2. The children will reside with the other parent at the following times during the Winter
Vacation each year:
  (      )   The second half of the winter vacation each year.


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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



  (    )    Other: ______________
  (    )    Other: ______________
Additional info add here:


                                SPRING VACATION SCHEDULE
1. During Spring Vacations from school each year, the   Mother (      )     Father (        )
children shall reside primarily with:
2. The children will reside with the other parent at the following times during the Spring Vacation
each year:
  (    )   The second half of the spring vacation each year.
  (    )   Other: ______________
  (    )   Other: ______________
 Additional info add here:


                               SUMMER VACATION SCHEDULE
1. During Summer Vacations from school each year,       Mother (      )      Father (           )
the children shall reside primarily with:
2. The children will reside with the other parent at the following times during the Summer
Vacation each year:
  (    )    The second half of the summer vacation each year.
  (    )    Other: ______________
  (    )    Other: ______________
Additional info add here:


                                  VACATION WITH PARENTS
The children should spend each parent's vacation with that parent each                  (           )
year
Vacations with parents should be as follows:
            Other: ______________
            Other: ______________
            Other: ______________
Additional info add here:


                   TRANSPORTATION ARRANGEMENTS – NOT EXPENSES


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             Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



If you want any provisions in the parenting plan regarding transportation arrangements (other
than expenses) between the parents, list them here:
                   Other: ______________
                   Other: ______________
                   Other: ______________
Additional info add here:


                             DECISION MAKING AND DISPUTE RESOLUTION
1. Primary decisions regarding the children should be made as follows:
Education Decisions: Mother (              )           Father (     )       Joint (     )
Non-emergency
Health Care:                  Mother (     )           Father (     )       Joint (     )
Religious Upbringing:           Mother (       )         Father (       )     Joint (       )
 (       )       The other party should be excluded from all decision making for the reason or reasons
                 checked on the next page.


2. Disputes between the parties should be handled by (check one):
     (       )    Counseling by local county family services or by ____________________
     (       )    Mediation by local county family services or by ____________________
     (       )    Arbitration by local county family services or by ____________________
     (       )    Court action ONLY - You may only check this box if you have also checked at least one
                  reason for special restrictions in Section “REASONS FOR SPECIAL RESTRICTIONS”
                  below.
Additional info add here:


3. The cost of any counseling, mediation or arbitration should be paid:
  (      )        ____ % by the mother and ____ % by the father
  (      )        based on each party's proportional income from line 6 of the child support worksheets
  (      )        as determined in the dispute resolution process
Additional info add here:


                                  REASONS FOR SPECIAL RESTRICTIONS
 (       )        1. There are no special restrictions on either parent (skip number 2 below)
                 2. The following are the reasons for the special restrictions:


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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



 (    )   Willful abandonment for an extended period of time or substantial refusal to perform
          parenting functions.
 (    )   Physical, sexual or a pattern of emotional abuse of a child.
 (    )   A history of domestic violence as defined in RCW 26.50.010(1) or an assault or sexual
          assault which causes grievous bodily harm or the fear of such harm.
 (    )   A long-term emotional or physical impairment which interferes with the performance
          of parenting functions as defined in RCW 26.09.004.
 (    )   The absence or substantial impairment of emotional ties between parent and child.
 (    )   The abusive use of conflict by the parent, which creates the danger of serious damage
          to the child's psychological development.
 (    )   A parent has withheld from the other parent access to the child for a protracted period
          without good cause.
 Additional info add here:

          If you are establishing or modifying the Child Support Provisions
          complete the following sections.


You must put some entry in EVERY blank. If you leave any blank empty, we will assume that the
answer is "$0". If you expect a change in jobs or income during the 90-day waiting period, you
should put down the income you expect to receive after the change.

If both parties have agreed to a lesser amount than the standard calculation please check here
(    ) and then enter the agreed upon amount here $     . You still must complete the following
sections.

If you are currently receiving/paying child support through DSHS/Support Enforcement or the
Court, you must provide us with a CERTIFIED COPY of the order from DSHS/Support
Enforcement or the Court as soon as possible as it may need to be filed with your petition
          EVERY ENTRY MUST BE FOR A MONTH - not hourly, weekly, etc. If you do not
          have pay stubs available, you can estimate. If you are not paid monthly, you will need
          to convert the to a monthly amount as follows:
                        If you are paid WEEKLY, multiply ALL amounts on your pay stub by 4.35
                        If you are paid EVERY TWO WEEKS multiply ALL amount on your stub
                        by 2.17
                        If you are paid SEMI-MONTHLY, multiply ALL amounts on your pay
                        stub by 2


1. MONTHLY GROSS INCOME:                                                       Father          Mother
          a. Wages, Salaries, & Tips                                     $                 $

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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



          b. Child Support or Public Assistance                          $                 $
          c. Interest and Dividend Income                               $                 $
          d. Business Income                                            $                 $
          e. Spousal Maintenance (Alimony) Received From                $                 $
          Former Spouse
          f. Other Income From: ______________________                  $                 $
Additional info add here:


2. MONTHLY DEDUCTIONS FROM GROSS INCOME:                                      Father           Mother
          a. Income Taxes                                                $                $
          b. FICA and/or Self-Employment Taxes                           $                $
          c. State Industrial Insurance Deductions                       $                $
          d. Required Union/Professional Dues                            $                $
          e. Required Pension Plan Payments                              $                $
          f. Spousal Maintenance (Alimony) Paid To A Former              $                $
          Spouse
          g. Normal Business Expenses                                    $                $
Additional info add here:


3. MONTHLY EXPENSES OF CHILDREN PAID DIRECTLY TO
THIRD PARTIES: List all expenses each parent is paying now and
all expenses each parent should be ordered to pay. The following
expense(s) should be paid by:                                                 Father           Mother
          a. Monthly Health Insurance Premiums                           $                $
          b. Uninsured Monthly Health Care Expenses                      $                $
          c. Day Care Expenses                                           $                $
          d. Education Expenses                                          $                $
          e. Long Distance Transportation Costs                          $                $
          f. Other Special Expenses (describe) ______________            $                $
          g. Other Special Expenses (describe) ______________            $                $
Additional info add here:


            PUBLIC ASSISTANCE (WELFARE) AND STATE MEDICAL ASSISTANCE
If either parent is receiving Public Assistance (welfare) or state medical assistance for the


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          Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



children,
    (    )    Neither parent is receiving Public Assistance (welfare) or state medical assistance for
              the children.
    (    )    MOTHER is receiving Public Assistance (welfare) or state medical assistance for the
              children.
    (    )    FATHER is receiving Public Assistance (welfare) or state medical assistance for the
              children.
Additional info add here:


                                OPTIONAL CHILD SUPPORT MATTERS
You must check one of the boxes in paragraph 1 (MEDICAL INSURANCE), but you are not
required to check any of the other boxes on this page unless you want the parent paying support
ordered to pay the expense you check IN ADDITION to regular monthly child support payments.
1. MEDICAL INSURANCE (REQUIRED):
The following parent shall provide health insurance for the children if the insurance is or becomes
available through employment or is union related and the cost of such coverage does not exceed
25% of the obligated parent's basic child support obligation:
                            Mother (     )          Father (   )      Joint (     )
    (     )   The same parent should be ordered to carry medical insurance even if it is not
              available through employment and is not union related.
    Additional info add here:


2. DENTAL INSURANCE AND EXPENSES (NOT REQUIRED):
(       ) The parent paying support should also be ordered to purchase dental insurance on the
          dependent children even if the insurance is no longer available through that parent's
          employment.
Dental expenses not covered by insurance
shall be paid by the:                             Mother (     ) Father (       ) Joint (   )
Additional info add here:


3. DIRECT PAYMENTS TO THIRD PARTIES BY PARENT PAYING SUPPORT (NOT
REQUIRED):
When should payment begin? (dd/mm/yyyy)
Frequency of payments (e.g. 1st & 15th of month)
Should the parent that pays child support pay the other parent directly or through Child Support
Enforcement?
(       ) Directly to other parent


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       Questionnaire: Petition to Modify Custody/Parenting Plan and/or Child Support Order



(    ) Child Support Enforcement
The parent paying support should also pay ____ % of the following expenses of the children
before they reach age eighteen:
                        Mother (      )         Father (   )   Joint (    )
(    ) Day Care
(    ) Education
(    ) Long Distance Transportation
(    ) Other: ______________
Additional info add here:


4. COLLEGE, BUSINESS SCHOOL, OR TRADE SCHOOL EXPENSES (NOT REQUIRED):
The following parent should be required to pay the college, business school or trade school
expenses of the children:
                        Mother (      )         Father (   )   Joint (    )
Additional info add here:




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DOCUMENT INFO