Free DR201 withholding order QMCSO information sheet.PDF - Ohio

DR Form 201 Revised 10/20/94

BUTLER COUNTY COMMON PLEAS COURT DIVISION OF DOMESTIC RELATIONS
WITHHOLDING ORDER/QUALIFIED MEDICAL CHILD SUPPORT ORDER INFORMATION SHEET DATE: ____________ REQUESTED BY: ___________________________________ CASE NO. ________________________ OBLIGOR (PERSON ORDERED TO PAY): ______________________________________________________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: _______ ZIP: _____________ SOCIAL SECURITY NUMBER: ______________________________________ PHONE: ____________________________ NAME AND ADDRESS OF EMPLOYER: __________________________________ EMPLOYER PHONE: _______________ PAY SCHEDULE: G Weekly _______________________________ ___________________________________ G Bi-weekly G Semi-monthly G Monthly ____________--__________________________ _______________________________ DATE OF BIRTH: _________________________ PAYROLL ADDRESS: ________________________________ __________________________________

MONTHLY OBLIGATION $ ___________ OBLIGATION PER PAY PERIOD $ FINANCIAL INSTITUTIONS NAME AND ADDRESS TYPE OF ACCOUNT

ACCOUNT NUMBER

___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ OBLIGEE (PERSON/AGENCY TO RECEIVE PAYMENTS): _______________________________________________________ DATE OF BIRTH: _________________________ G Non-IV-D ____________________________

ADDRESS: ______________________________________ CITY: __________________ STATE: _______ ZIP: _____________ SOCIAL SECURITY NUMBER: ______________________________________ PHONE: ________________________________________ CASE TYPE: G IV-D Non-ADC G IV-D ADC

Number of minor children for whom support is paid (Alternate Recipients covered by insurance)

CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: _________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ RESIDENTIAL PARENT/LEGAL GUARDIAN: __________________________________________________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: ________________

ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ RESIDENTIAL PARENT/LEGAL GUARDIAN: __________________________________________________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ CHILD'S NAME: ________________________ SOC. SEC. NO: ____________________ DATE OF BIRTH: RESIDENTIAL PARENT/LEGAL GUARDIAN: ________________

ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ _______________________________________________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________

PARTICIPANT (PERSON ORDERED TO PROVIDE INSURANCE):

________________________________________________

PROVIDER OF INSURANCE IS: G Obligor G Obligor's Spouse _________________ G Other _________________________ ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ SOCIAL SECURITY NUMBER: ______________________________________ DATE OF BIRTH: _________________________ EMPLOYER: ______________________________________________________________________________________________ EMPLOYER ADDRESS: ____________________________________________________________________________________ ______________________________________________________________________________________________________ _____ EMPLOYER PHONE: _______________________________________________________________________________________ INSURANCE IS UNDER: G GROUP PLAN G PRIVATE PLAN NAME(S) OF PLAN(S): ______________________________________________________________________________________ NAME(S) / ADDRESS(ES) OF PLAN ADMINISTRATOR(S): _______________________________________________________ ______________________________________________________________________________________________________ _____ ______________________________________________________________________________________________________ _____ POLICY AND/OR GROUP NUMBER(S): ________________________________________________________________________ DESCRIPTION OF TYPE OF COVERAGE TO BE PROVIDED: _____________________________________________________ ___________________________________________________________________________________________________________

PARTICIPANT (PERSON ORDERED TO PROVIDE INSURANCE):

_________________________________________________ G Other ________________________

PROVIDER OF INSURANCE IS: G Obligee G Obligee's Spouse ________________ SOCIAL SECURITY NUMBER: ______________________________________

ADDRESS: ______________________________________ CITY: __________________ STATE: ______ ZIP: ______________ DATE OF BIRTH: _________________________ EMPLOYER: ______________________________________________________________________________________________ EMPLOYER ADDRESS: ____________________________________________________________________________________ ______________________________________________________________________________________________________ _____ EMPLOYER PHONE: _______________________________________________________________________________________ INSURANCE IS UNDER: G GROUP PLAN G PRIVATE PLAN NAME(S) OF PLAN(S): ______________________________________________________________________________________ NAME(S) / ADDRESS(ES) OF PLAN ADMINISTRATOR(S): _______________________________________________________ ______________________________________________________________________________________________________ _____ ______________________________________________________________________________________________________ _____ POLICY AND/OR GROUP NUMBER(S): ________________________________________________________________________ DESCRIPTION OF TYPE OF COVERAGE TO BE PROVIDED: _____________________________________________________ ______________________________________________________________________________________________________ _____

PLEASE COMPLETE BOTH SIDES OF THIS FORM. FORM MAY NOT BE ACCEPTED IF NOT COMPLETED IN FULL AND LEGIBLY TYPED OR WRITTEN.

Return form with appropriate entries in compliance with Rule 6 of the Court of Common Pleas, Division of Domestic Relations, to the Compliance Office; Government Services Centers, 315 High Street, Second Floor, Hamilton, Ohio 45011; phone (513) 887-3693.