Free - Ohio

Appendix A ­ Child Support Language 3/09

If the order is pursuant to the guidelines, the following language must be contained in the entry: The child support order is pursuant to the guidelines: "Based upon Father's adjusted gross income of $________ per year, and Mother's adjusted gross income of $_________ per year, an award of child support, in accordance with child support guidelines, ORC 3119.021, is payable as follows: When private health insurance IS being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), which includes the 2% processing fees. When private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), for the minor children, which includes the 2% processing fees. When private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay cash medical support in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period), which includes the 2% processing fees. Said order is effective ___________and the order of support shall be paid through CSEA or OCSPC. (Choose one) Insurance is available. The obligor shall pay child support in the amount of ___________ per month, per child, which includes the 2% processing fee. If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL BEGIN paying cash medical support commencing the first day of the month immediately following the month in which private health insurance coverage became unavailable or is terminated, and SHALL CEASE paying cash medical support on the last day of the month immediately preceding the month in which private health insurance coverage begins or resumes. Cash medical support shall be paid in addition to child support." or

Appendix A ­ Child Support Language 3/09

Insurance is not available. The obligor shall pay child support in the amount of ____________ per month, per child, which includes the 2% processing fee and the cash medical support order in the amount of __________ per month, which includes the 2% processing fee and is payable to: CSEA for disbursement to the obligee since the child(ren) do not receive State or Federal medical assistance or card or CSEA since the child(ren) do receive State or Federal medical assistance or card. If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL BEGIN paying cash medical support commencing the first day of the month immediately following the month in which private health insurance coverage became unavailable or is terminated, and SHALL CEASE paying cash medical support on the last day of the month immediately preceding the month in which private health insurance coverage begins or resumes. Cash medical support shall be paid in addition to child support." If there is a deviation to the guidelines, the following language must be contained in the entry: The child support order deviates from the guidelines: "Based upon Father's adjusted gross income of $________ per year, and Mother's adjusted gross income of $_________ per year, an award of child support, in accordance with child support guidelines, ORC 3119.021, is payable as follows: When private health insurance IS being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), which includes the 2% processing fees. When private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), for the minor children, which includes the 2% processing fees. The amount of guideline child support pursuant to ORC 3119.021 is unjust or inappropriate and not in the best interest of the minor child(ren.) A deviation pursuant to ORC 3119.22 is appropriate for the reason that (state reason(s): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________.

Appendix A ­ Child Support Language 3/09

Based on the deviation factors contained in ORC 3119.23 and 3119.24, a deviation from guideline support is in the best interest of the minor child(ren) and payable as follows: When private health insurance IS being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), which includes the 2% processing fees. When private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period) to the Child Support Obligee, and/or his/her assignee(s), for the minor children, which includes the 2% processing fees. When private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay cash medical support in the sum of $_____________ per month ($_____________ per month per child) ($__________ per ___________ pay period), which includes the 2% processing fees. Said order is effective ___________and the order of support shall be paid through CSEA or OCSPC. (Choose one) Insurance is available. The obligor shall pay child support in the amount of ___________ per month, per child, which includes the 2% processing fee. If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL BEGIN paying cash medical support commencing the first day of the month immediately following the month in which private health insurance coverage became unavailable or is terminated, and SHALL CEASE paying cash medical support on the last day of the month immediately preceding the month in which private health insurance coverage begins or resumes. Cash medical support shall be paid in addition to child support." or Insurance is not available. The obligor shall pay child support in the amount of ____________ per month, per child, which includes the 2%

Appendix A ­ Child Support Language 3/09

processing fee and the cash medical support order in the amount of __________ per month, which includes the 2% processing fee and is payable to: CSEA for disbursement to the obligee since the child(ren) do not receive State or Federal medical assistance or card or CSEA since the child(ren) do receive State or Federal medical assistance or card. If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL BEGIN paying cash medical support commencing the first day of the month immediately following the month in which private health insurance coverage became unavailable or is terminated, and SHALL CEASE paying cash medical support on the last day of the month immediately preceding the month in which private health insurance coverage begins or resumes. Cash medical support shall be paid in addition to child support."