Free - Ohio

C15 ­ Rev. 3/09

IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Judge Sharon L. Kennedy Judge Eva D. Kessler __________ Plaintiff/First Petitioner/Petitioner Case No.________________ Mandatory Support Language ___________________________________ Defendant/Second Petitioner/Respondent IT IS FURTHER ORDERED: (Choose one of the following) 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

C15 ­ Rev. 3/09

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% 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." 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)): ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________.

C15 ­ Rev. 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% 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

C15 ­ Rev. 3/09

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." IT IS FURTHER ORDERED that the duty of support shall continue beyond the age of majority as long as the child continuously attends on a full-time basis any recognized and accredited high school. A child support order shall not remain in effect after the children reaches nineteen years of age unless the order provides that the duty of support continues under circumstances described in ORC 3119.86(A)(1)(a) or (b). IT IS FURTHER ORDERED that all support under this order shall be withheld or deducted from the income or assets of the obligor pursuant to a withholding or deduction notice or appropriate Court order issued in accordance with sections 3121.02 to 3121.07 of the Revised Code or a withdrawal directive issued pursuant to section 3123.37 of the Revised Code and shall be forwarded to the obligee in accordance with section 3121.50 of the Revised Code. IT IS FURTHER ORDERED that until such time as a withholding or deduction order is in effect, the obligor shall discharge his or her obligation by making payments directly to the CSEA or the division of child support in the Ohio Department of Job and Family Services, as appropriate. IT IS FURTHER ORDERED that the obligor is restrained from making said payments directly to the obligee, and the obligee is enjoined from accepting direct payments from the obligor. Any payments of support not made through the CSEA or the division of child support in the Ohio Department of Job and Family Services, as appropriate, shall be deemed a gift. EACH PARTY TO THIS SUPPORT ORDER MUST NOTIFY THE CHILD SUPPORT ENFORCEMENT AGENCY IN WRITING OF HIS OR HER CURRENT MAILING ADDRESS, CURRENT RESIDENCE ADDRESS, CURRENT RESIDENCE TELEPHONE NUMBER, CURRENT DRIVER'S LICENSE NUMBER, AND OF ANY CHANGES IN THAT INFORMATION. EACH PARTY MUST NOTIFY THE AGENCY OF ALL CHANGES UNTIL FURTHER NOTICE FROM THE COURT. IF YOU ARE THE OBLIGOR UNDER A CHILD SUPPORT ORDER AND YOU FAIL TO MAKE THE REQUIRED NOTIFICATIONS YOU MAY BE FINED UP TO $50.00 FOR A FIRST OFFENSE, $100.00 FOR A SECOND OFFENSE, AND $500.00 FOR EACH SUBSEQUENT OFFENSE. IF YOU ARE AN OBLIGOR OR OBLIGEE UNDER ANY SUPPORT ORDER AND YOU WILLFULLY FAIL TO MAKE THE REQUIRED NOTIFICATIONS YOU MAY BE FOUND IN CONTEMPT OF COURT AND BE SUBJECTED TO FINES UP TO $1,000.00 AND IMPRISONMENT FOR NOT MORE THAN NINETY (90) DAYS. IF YOU ARE AN OBLIGOR AND YOU FAIL TO MAKE THE REQUIRED NOTIFICATIONS YOU MAY NOT RECEIVE NOTICE OF THE FOLLOWING ENFORCEMENT LIENS AGAINST YOU: IMPOSITION OF LIENS AGAINST YOUR PROPERTY; LOSS OF YOUR PROFESSIONAL OR OCCUPATIONAL LICENSE, DRIVER'S LICENSE, OR RECREATIONAL LICENSE; WITHHOLDING FROM YOUR INCOME; ACCESS RESTRICTION AND DEDUCTION FROM YOUR ACCOUNTS IN FINANCIAL INSTITUTIONS; AND ANY OTHER ACTION PERMITTED BY LAW TO OBTAIN MONEY FROM YOU TO SATISFY YOUR SUPPORT OBLIGATION.

C15 ­ Rev. 3/09

IT IS FURTHER ORDERED that obligor and obligee immediately notify the CSEA in writing of any change in the obligor's income source and of the availability of any other sources of income that can be the subject of a withholding order. This duty to notify the CSEA shall continue until further notice from the Court. A failure to provide such notification may make the obligor liable for retroactive support that would otherwise have been ordered. IT IS FURTHER ORDERED that the obligor and oblige shall immediately notify the CSEA, in writing, of any change in the status of the minor children of the parties, which would terminate or modify the duty of the obligor to pay support. IT IS FURTHER ORDERED that if the obligee is to receive spousal support from the obligor, the obligee shall immediately notify the CSEA, in writing, of remarriage if the remarriage would terminate the obligation to pay spousal support. To make payments through the Butler County CSEA: Make cash or credit card payments only at the following location: Butler County Child Support Enforcement Agency, Government Services Center, 315 High Street, 8th Floor, Hamilton, Ohio 45011. Acceptable methods of payment are as follows: Visa, MasterCard, ATM, and Cash payments may be made locally in person only. Do not send cash by mail. Personal checks will not be accepted by the Butler County CSEA." To make payments to the Ohio Child Support Payment Central (OCSPC): The obligor shall send payments to the following location: Ohio Child Support Payment Central, P.O. Box 182372, Columbus, Ohio 43218. The employer shall send payments to the following location: Ohio Child Support Payment Central, P.O. Box 182394, Columbus, Ohio 43218. Acceptable methods of payment to OCSPC are as follows: certified check, cashier's check, personal check, or money order. IT IS FURTHER ORDERED that both the obligor and obligee are liable for health care of the children who are not covered by private health insurance or cash medical support; IT IS FURTHER ORDERED that any person providing health insurance coverage shall, not later than 30 days after issuance of the order, provide all information regarding benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under to coverage, and a copy of any necessary insurance cards; IT IS FURTHER ORDERED that the health plan administrator may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the plan; IT IS FURTHER ORDERED that any person required to provide health insurance coverage for children shall designate the child(ren) as covered dependents under any private health insurance policy, contract, or plan.

C15 ­ Rev. 3/09

IT IS FURTHER ORDERED: (Choose one of the following) If one of the parties has health insurance: "__________________________ shall provide the primary health insurance for the parties' minor child(ren) so long as the health insurance is available through employment at a reasonable cost as defined in ORC 3119.30. _________________________ shall obtain secondary health insurance for the parties' minor child(ren) when it becomes available through employment at a reasonable cost as defined in ORC 3119.30. Upon receipt of the health insurance ___________________________ shall within 14 days of obtaining coverage inform the Child Support Enforcement Agency. In the future, the parties shall, upon receipt of new health insurance information regarding benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under to coverage, and a copy of any necessary insurance cards provide all updated information to the other party within fourteen (14) days. The parties shall divide all co-pays, deductible costs required under the health insurance policy and all other uncovered health care expenses as follows, father shall pay ______% and mother shall pay ______%. The parties shall provide each other with a copy of all health care bills for the minor child(ren) on a quarterly basis and a summary of all amounts paid by either party. The summary shall include an offset against all cash medical support received. The documentation of health care expenses shall be provided on the last day of the months of March, June, September, and December. Payment/reimbursement for all health care expenses shall be made within thirty (30) days. Absent extraordinary circumstances, motions for payment of health care bills must be made within one (1) year of the date the bills were incurred. The parties shall use all health and dental care providers within the health and dental care plan, unless the parties have entered into a written agreement. Any party who uses a health or dental care provider outside of the health and dental care plan shall solely pay said debt. The only exceptions to this provision are a medical emergency or a health and dental care provider under the plan does not exist in their area. Medical emergency is defined as a life threatening illness or serious injury." If both of the parties have health insurance: "________________________________ shall provide the primary health insurance for the parties' minor child(ren) so long as the health insurance is available through employment at a reasonable cost as defined in ORC 3119.30._______________________ shall provide the secondary health insurance for the parties' minor child(ren) so long as the health insurance is available through employment at a reasonable cost as defined in ORC 3119.30.

C15 ­ Rev. 3/09

In the future, the parties shall upon receipt of new health insurance information regarding benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under to coverage, and a copy of any necessary insurance cards provide all updated information within fourteen (14) days. The parties shall divide all co-pays, deductible costs required under the health insurance policy and all other uncovered health care expenses as follows, father shall pay ______% and mother shall pay ______%. The parties shall provide each other with a copy of all health care bills for the minor child(ren) on a quarterly basis and a summary of all amounts paid by either party. The summary shall include an offset against all cash medical support received. The documentation of health care expenses shall be provided on the last day of the months of March, June, September, and December. Payment/reimbursement for all health care expenses shall be made within thirty (30) days. Absent extraordinary circumstances, motions for payment of health care bills must be made within one (1) year of the date the bills were incurred. The parties shall use all health and dental care providers within the health and dental care plan, unless the parties have entered into a written agreement. Any party who uses a health or dental care provider outside of the health and dental care plan shall solely pay said debt. The only exceptions to this provision are a medical emergency or a health and dental care provider under the plan does not exist in their area. Medical emergency is defined as a life threatening illness or serious injury." If neither of the parties has health insurance: "Both parties shall provide health insurance for the child(ren) whenever it is available through their employment at a reasonable cost as defined in ORC 3119.30. Upon receipt of the health insurance the party shall within fourteen (14) days of obtaining coverage inform the Child Support Enforcement Agency. In the event either party obtains health insurance, that party shall upon receipt of new health insurance information regarding benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under to coverage, and a copy of any necessary insurance cards provide all updated information within fourteen (14) days. The parties shall divide all co-pays, deductible costs required under the health insurance policy and all other uncovered health care expenses as follows, father shall pay ______% and mother shall pay ______%. The parties shall provide each other with a copy of all health care bills for the minor child(ren) on a quarterly basis and a summary of all amounts paid by either party. The summary shall include an offset against all cash medical support received.

C15 ­ Rev. 3/09

The documentation of health care expenses shall be provided on the last day of the months of March, June, September, and December. Payment/reimbursement for all health care expenses shall be made within thirty days. Absent extraordinary circumstances, motions for payment of health care medical bills must be made within one (1) year of the date the bills were incurred. The parties shall use all health and dental care providers within the health and dental care plan, unless the parties have entered into a written agreement. Any party who uses a health or dental care provider outside of the health and dental care plan shall solely pay said debt. The only exceptions to this provision are a medical emergency or a health and dental care provider under the plan does not exist in their area. Medical emergency is defined as a life threatening illness or serious injury." IT IS FURTHER ORDERED if either or both parents have health insurance available to them through a group policy, an order for obligee and/or obligor to provide health insurance (Form DR 705) shall issue. If neither parent has health insurance available through a group policy and neither is able to afford private insurance, an order for the payment of medical expenses (Form DR 707) shall issue. If neither parent has health insurance available through a group policy, but one or both has the means of providing private insurance, an order to provide private insurance (Form DR 708) shall issue. IT IS FURTHER ORDERED that the parties must comply with any obligations concerning health insurance coverage imposed under section 3119.30 to 3119.31 of the Revised Code no later than thirty (30) days after the applicable order is issued. IT IS FURTHER ORDERED that any person who fails to provide health insurance as ordered may be punished for contempt of Court and shall be solely responsible for the payment of all health care expenses incurred on the child(ren)'s behalf as a result of the failure to provide insurance. If the obligor is found in contempt for failing to provide health insurance coverage and the obligor has previously been found in contempt under Chapter 2705 of the Revised Code, the Court shall consider the obligor's failure to comply with the order as a change of circumstances for the purpose of modification of the amount of support due under the child support order that is the basis of the order issued under Revised Code 3119.30 to 3119.31. IT IS FURTHER ORDERED: (Choose one of the following) Division of Dependent(s) and Alternating Remaining Dependent(s) Mother shall claim the following dependent(s)________________________________ ________________________________________________________________________ _____ for all federal, state, and local income tax purposes and Father shall claim the following dependent(s)_____________________________________________________ ____________________________________for all federal, state, and local income tax purposes. When only one dependent remains then Mother shall claim the child(ren) as dependents in even odd years for all federal, state, and local income tax purposes and Father shall claim the child(ren) as dependents in even odd years for all federal, state, and local income tax purposes. Alternating Dependent(s) Yearly Mother shall claim the child(ren) as dependents in even odd years for all federal,

C15 ­ Rev. 3/09

state, and local income tax purposes and Father shall claim the child(ren) as dependents in even odd years for all federal, state, and local income tax purposes. Other ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. IT IS FURTHER ORDERED that any person who may claim a dependent for federal, state, and local income tax purposes shall be substantially current in payment of child support for any tax year for which the child(ren) are claimed as dependents. A child support obligor shall be substantially current in payment of child support if less than $100 arrears are owed for the tax year for which the child or children are to be claimed as dependent(s), on or before January 31st of the following year. (ORC 3119.82) IT IS FURTHER ORDERED the residential parent of a child, including any party to a shared parenting decree and any other legal custodian, shall send a notice of intent to relocate to the Domestic Relations Court Case Management Office, as follows: If a parent or other legal custodian desires to move, he/she must notify, in writing: (i) (ii) (iii) The other parent; The Domestic Relations Court Case Management Office; The Butler County Child Support Enforcement Agency (CSEA).

Notice must be sent within the following time frames: (i) (ii) If relocating within Butler County- at least thirty (30) days in advance of the move. If relocating outside Butler County- at least sixty (60) days in advance of the move.

Written notice must be submitted to the Case Management Office on Form C-13, if relocating within Butler County, and on Form C-13A, if relocating outside Butler County. If either parent believes the relocation requires a change in the allocation of parenting time, it is the responsibility of that parent to file a motion to review the allocation of parenting time.

C15 ­ Rev. 3/09

If a parent believes that the move requires a change in residential parent status, that parent may file a motion for change of residential parent or modification of the shared parenting plan, in accordance with Rule DR 36(E). IT IS FURTHER ORDERED that each parent, or other legal custodian, shall have equal access to the children's school, day care center, medical or educational records and extracurricular or recreational activities. Any school, day care center official, medical, educational, and extracurricular or recreational activity coordinator or keeper of all records shall provide each parent or legal custodian with all records, documents, and materials related to the child(ren). Failure to comply with this order may be punishable as contempt of Court. ____________________________________________ Plaintiff/First Petitioner/Petitioner _____________________________________________ Defendant/Second Petitioner/Respondent _____________________________________________ Attorney for Plaintiff/First Petitioner/Petitioner Date: ______________________ Date: ______________________ Date:______________________

______________________________________________ Date:______________________ Attorney for Defendant/Second Petitioner/Respondent