Name 

 
Address 

 
Phone 

 
Email 

 
City, State, Zip 

 
 
 
 
 
 
 
 
 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of (select one) 
 

[  ]  the Marriage of (for a divorce with or without 
children, annulment, separate maintenance, or 
temporary separation case) 

[  ]  the Children of (to establish custody, parent-

time or child support) 

[  ]  the Parentage of the Children of (for a 

paternity case) 

____________________________________ 
(name of Petitioner) 

and  

____________________________________ 
(name of Respondent) 
____________________________________________ 
Other parties (if any) 

Order on Petition to Modify Child 
Support 
(Utah Rule of Civil Procedure 106) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner  

The matter before the court is a Petition to Modify Child Support. This matter is being 
resolved by: (Choose all that apply.) 

[  ]  The default of     [  ] petitioner     [  ] respondent. 

[  ]  The stipulation of the parties. 

[  ]  The pleadings and other papers of the parties. 

[  ]  A hearing held on __________________________ (date), notice of which was 

served on all parties. 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 1 of 9 

 

[  ]  was represented by _______________________ 

Petitioner 

[  ]  was   [  ] was not present  

[  ]  was not represented. 

Respondent 

[  ]   was   [  ] was not present  

 

 

[  ]   was represented by _______________________ 

[  ]   was not represented. 

The court orders: 

1. 

The petition is:   

[  ] denied.  

 

 

follows. 

2. 

[  ]  Child support 

[  ] granted. The controlling order dated ___________ (date) is modified as 

a.  Petitioner’s total countable gross monthly income for child support 

purposes is $________________ (Utah Code 78B-12-203).  

[  ]  Petitioner’s income is imputed based on: 

 

[  ] minimum wage. 

[  ] historical earnings. 

[  ]  Petitioner does receive or has received public assistance. 

b.  Respondent’s total countable gross monthly income for child support 

purposes is $________________ (Utah Code 78B-12-203).  

[  ]  Respondent’s income is imputed based on: 

 

[  ] minimum wage. 

[  ] historical earnings. 

[  ]  Respondent does receive or has received public assistance. 

c.  [  ] Petitioner   [  ] Respondent must pay $________________ per month 

for child support. The following child support worksheet is attached (Choose 
one.):  

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 2 of 9 

 

[  ]  sole physical custody worksheet 

[  ]  joint physical custody worksheet 

[  ]  split custody worksheet 

(Choose one.) 

Code 78B-12-2). 

[  ]  This amount is based on the Uniform Child Support Guidelines (Utah 

[  ]  This amount deviates from the Uniform Child Support Guidelines.  
The court finds that a deviated child support amount is in the best 
interests of the minor children based on: 

[  ]  the standard of living and situation of the parties. 

[  ]  the relative wealth and income of the parties. 

[  ]  the obligor’s (person who pays support) ability to earn. 

[  ]  the ability of the obligee (person who receives support) to earn. 

[  ]  the ability of an incapacitated adult child to earn, or other 

benefits received by the adult child or on the adult child's behalf 
including Supplemental Security Income. 

[  ]  the needs of the obligee, the obligor, and the child. 

[  ]  the responsibilities of the obligor and the obligee for the support 

[  ]  the ages of the parties. 

of others. 

[  ]  other. (Describe.):  

___________________________________________________ 

The reason for the deviated child support amount is:  

_______________________________________________________ 

_______________________________________________________ 

______________________________________________________. 

d.  Effective date (Choose one.): 

[  ]  The child support will be effective upon entry of this order.  

OR 

[  ]  The child support will be effective as of this date: ________________. 

e.  Child support must be paid as follows (Choose one.): 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 3 of 9 

 

[  ]  Mandatory income withholding by the Office of Recovery Services.  
Unless the Office of Recovery Services gives notice that payments 
should be sent elsewhere, all child support payments must be made to:  
Office of Recovery Services, PO Box 45011, Salt Lake City, UT 84145  

[  ]  Direct payments to the parent receiving child support by: 

OR 

[  ]  Check 

[  ] Deposit in bank account 

[  ] Cashier’s check or money order 

[  ] Other: ________________________________________________ 

f.  Child support payments must be made (Choose one.): 

[  ]  One-half on or before the 5th day of each month, and one-half on or 

before the 20th day of each month. 

OR 

[  ]  Other payment arrangement: 

________________________________________________________ 

g.  Child support not paid on or before the due date is past due on the day 

after the due date.  

h.  Past-due child support will be determined by further judicial or 

administrative process. Any federal or state tax refund or rebate due to the 
non-custodial parent will be intercepted by the state of Utah and applied to 
child support arrearages. 

• Both parties share equally all reasonable child care expenses related to the 

custodial parent's work or occupational training. 

• The parent who pays child care expenses must immediately provide to the 
other parent written verification of the cost of the child care expenses and 
the identity of the child care provider when hired, within 30 calendar days 
after a change in the provider or the expense, and anytime upon the request 
of the other parent. 

• If the parent who pays child care expenses does not provide written 

verification of child care, that parent may be denied the right to recover or 
receive credit for the other parent's one-half share of the child care 
expense. 

3. 

[  ]  Child care expenses 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 4 of 9 

 

• The other parent must begin paying one-half the child care amount on a 

monthly basis immediately after receiving proof from the parent that pays 
the child care expense. 

  ]  Other order for child care payment:  

  [

 

   

4. 

 

[  ]  Health insurance, medical and dental expenses 

The minor children currently have health insurance coverage through: 

[  ]  Petitioner’s insurance 

[  ]  Respondent’s insurance 

[  ]  Medicaid 

[  ]  CHIP 

[  ]  Not covered by insurance 

[  ]  Other: _______________________________________________ 

[  ] 

[  ] Petitioner   [  ] Respondent must maintain health insurance for the minor 
children if it is available to that parent at a reasonable cost. Both parties 
must share equally: 

a.  the cost of the premium paid by a parent for the children's portion of the 
insurance. The children's portion of the premium will be calculated by 
dividing the premium amount by the number of people covered by the 
policy and multiplying the result by the number of minor children of the 
parties; and 

b.  all reasonable and necessary uninsured medical and dental expenses 

incurred for the children and paid by a parent, including deductibles and 
co-payments. 

The parent ordered to maintain insurance must provide written verification of 
coverage to the other parent or the Office of Recovery Services when the 
children are first enrolled, on or before January 2nd of each calendar year 
and upon any change of insurance carrier, premium, or benefits within 30 
calendar days after the date that parent knew or should have known of the 
change. 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 5 of 9 

 

If the parent ordered to maintain insurance fails to provide written 
verification of coverage to the other parent or to the Office of Recovery 
Services, or if the parent incurring medical expenses fails to provide written 
verification of the cost and payment of the expenses to the other parent 
within 30 days of payment, that parent may be denied the right to receive 
credit for the expenses or to recover the other parent's share of the 
expenses.  

The parent receiving written verification must reimburse the parent who 
incurred the medical or dental expenses one-half of the amount within 30 
days after receiving the written verification. 

[  ]  Other order for health insurance, medical and dental expenses:  

[  ]  ____________________________________________________ (name) 
will claim the children as dependents/exemptions for tax purposes. 

[  ]  ____________________________________________________ (name) 
will claim the children as dependents/exemptions for tax purposes in 
even years, and 
_________________________________________________ (name) will 
claim the children as dependents/exemptions for tax purposes in odd 
years. 

[  ]  claiming children as dependents/exemptions for tax purposes will be 

divided as follows: 

Child’s name 

Month and 
year of birth 

Parent who will 
claim child as 
dependent / 
exemption 

[  ] Petitioner      
[  ] Respondent 

[  ] Petitioner      
[  ] Respondent 

 

 

 

78B-12-217) 

(Choose one.) 

   

 

 

5. 

[  ] Claiming children as dependents/exemptions for tax purposes (Utah Code 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 6 of 9 

 

[  ] Petitioner      
[  ] Respondent 

[  ] Petitioner      
[  ] Respondent 

[  ] Petitioner      
[  ] Respondent 

 

 

 

6. 

[  ] Attorney fees and costs 

[  ]  Petitioner    [  ]  Respondent  must pay $___________ in attorney fees 
and $___________ in costs. 

7. 

[  ]  Other orders 

8. 

Remainder of order unchanged 

The provisions of any previous order not modified by this order remain in effect. 

ommissioner’s or judge’s signature may instead appear at the top of the first page of this document. 

Signature ► 

Commissioner 

Signature ► 

Judge 

 

 

 

 

  C

 
Date 

 
Date 

 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 7 of 9 

 [  ]  Other:  

   

 

 

 

     

 

Approved as to form. 

Signature ► 

Petitioner, Attorney or Licensed Paralegal 
Practitioner 

Signature ► 

Respondent, Attorney or Licensed Paralegal 
Practitioner 

 

 

 

 

 
Date 

 
Date 

 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 8 of 9 

 

 

 

 

Certificate of Service 

I certify that I filed with the court and am serving a copy of this Order on Petition to Modify Child Support 
on the following people. 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

 

 

 

 

 
Date 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

 

 

 

Signature ► 

Printed Name 

 

 

1137FAJ Approved January 27, 2020 / 
Revised May 1, 2022 
 

Order on Petition to Modify Child Support 

Page 9 of 9