COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) IN THE COURT OF COMMON PLEAS OF ASHLAND COUNTY, OHIO -against: DOMESTIC RELATIONS DIVISION : _____________________________, Plaintiff/Petitioner : Case No. ___________________ Defendant(s) : . . . . . . . . . . . . . .vs/and. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... _____________________________, THE PEOPLE OF THE STATE Defendant/Petitioner OF NEW YORK HEALTH INSURANCE ORDER O.R.C. 3119.30 et seq. (Rev. 9-13-03) TO The following group health insurance and health care policies, contracts, and plans are available at a reasonable cost to the obligor or obligee: Name of Plan/Insurer GREETINGS: Available to: Policy/Contract # WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of(Complete one of the following four (4) alternative ORDERS - Delete any not required) in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testifyALTERNATIVE 1: ORDER ONthis action on-the part of the and give evidence as a witness in OBLIGOR R.C. 3119.30(A)  The Court finds that the Obligor under the child support order is __________________ _________________ and that the Obligor should be ordered to obtain group health insurance coverage through: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Name of Employer or Group Plan and that health insurance coverage is not available at a more ,reasonable cost through a Witness, Honorable one of the Justices of the group healthCounty, insurance orday of care policy, contract or plan available to the Obligee. health Court in , 20 IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that no later than 30 days after the issuance of this order, the Obligor shall obtain health insurance coverage for (Attorney must sign above and type name below) the following child(ren): Name Date of Birth Attorney(s) for S. S. Number Office and P.O. Address and furnish written proof to the Ashland County Child Support Enforcement Agency that the required health insurance coverage has been obtained. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) ALTERNATIVE 2: ORDER ON OBLIGEE - R.C. 3119.30(B) -against: The Court finds that the Obligee under the child support order is __________________ : _________________ and that the Obligee should be ordered to obtain group health insurance coverage through: :  Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name . . Employer or. Group Plan . . . . of . . . . . . . . . and that health insurance coverage is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to the Obligor. THE PEOPLE OF THE STATE OF NEW YORK ADJUDGED AND DECREED that no later than 30 days IT IS THEREFORE ORDERED, after the issuance of this order, the Obligee shall obtain health insurance coverage for the following child(ren): TO Name Date of Birth S. S. Number GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed and furnish written proof to the Ashland County Child Support Enforcement Agency that the or adjourned date, to testify and give evidence as a witness in this action on the part of the required health insurance coverage has been obtained. ALTERNATIVE 3: ORDER ON punishable AND OBLIGEE - R.C. 3119.30(D) Your failure to comply with this subpoena isOBLIGOR as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a The Court finds result of your failure to comply. that health insurance is available at a reasonable cost to both the obligor and obligee and that dual coverage of both parents would provide for coordination of medical benefits without unnecessary duplication of coverage. Witness, Honorable , one of the Justices of the Court in day of , 20 IT IS County, THEREFORE ORDERED, ADJUDGED AND DECREED that within 30 days of the issuance of this order, both obligor and obligee provide health insurance coverage for the following child(ren):  (Attorney must sign above and type name below) Name Date of Birth S. S. Number Attorney(s) for Office and P.O. Address and furnish written proof to the Ashland County Child Support Enforcement Agency that the required health insurance coverage has been obtained. Telephone No.: Facsimile No.: 2 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA -againstALTERNATIVE 4: NEITHER PARTY HAS INSURANCE - R.C. 3119.30(C) :  The Court finds that health insurance is not : available at a reasonable cost to either the obligor and obligee, and that both parties shall share liability for the cost of the medical and health care needs of their children. : Defendant(s) IT IS THEREFORE ORDERED, ADJUDGED :AND DECREED that the parties shall share . . . . . . . all . health. . . . . . and. . . . . . . . . expenses .incurred .for . the benefit of the parties following minor . . . . . . . care . . . medical . . . . . . . . . . . . . . . . . . child(ren): Name THE PEOPLE OF THE STATE OF NEW YORK Date of Birth S. S. Number TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, youthat the parties'attend before IT IS FURTHER ORDERED, ADJUDGED AND DECREED, and each of you respective the Honorable of all health care and medical expenses incurred for the children shall be paid pursuant to , at the Court share County of terms of the Court'slocatedDR Rule 21, with the residential parent paying the first $100.00 per the Local at year per in room calendar , on the child of of health care or medical expensesin the child(ren) for whom they day any , 20 , at o'clock for the noon, and at any recessed are date, to testify and give evidence as ______% this action on the part the non-residential parent or adjourned residential parent, together with a witness in of the balance, and of the paying ______% of the balance of any health care or medical expense incurred for the benefit of the child(ren) in excess of the first $100.00 per calendar year per child. Your failure FURTHER ORDERED, ADJUDGED and DECREED that if, after the issuance of this to IT IS to comply with this subpoena is punishable as a contempt of court and will make you liable the party on whose behalf this subpoena was issued for child(ren) becomes available all damages sustained as a Order, health insurance coverage for the a maximum penalty of $50 and at a reasonable cost result of through a group policy, contract or plan offered by the obligor's or obligee's employer, or through your failure to comply. any other group policy, contract or plan available to the obligor or obligee, then the obligor or obligee to Honorable coverage becomes available shall immediatelyof the Justices of the addition, Witness, whom the , one inform the Court. In the obligor or the obligee to whom such health insurance coverage becomes available shall Court in obtain such health insurance of County, day coverage for ,the children identified above. 20 IT IS FURTHER ORDERED, ADJUDGED AND DECREED that if the Obligor or Obligee obtains health insurance pursuant to this Order, the partymust sign above and type name below) (Attorney obtaining insurance shall provide the other party with information regarding benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment or other benefits under the health insurance coverage, and a copy of any necessary insurance cards; that Attorney(s) for the party obtaining insurance submit a copy of this order to the insurer at the time application is made to enroll the children and furnish, no later than 30 days after the issuance of this order, written proof to the C.S.E.A. that the foregoing orders have been complied with. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that both obligor and obligee Office and equal to the be responsible for co-payments/deductible costs in amountsP.O. Address percentages indicated on Line 16 of the Ohio Child Support Guidelines Computation Worksheet unless otherwise specifically provided for in this order (above), or any other order of the Court. Telephone No.: Facsimile No.: 3 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA Both the obligor and the obligee shall designate their child(ren) as covered dependents -against: under any health insurance policy, contract, or plan for which they contract pursuant to R.C. 3119.31. : Reimbursement for out-of-pocket medical, optical, hospital, dental, prescription, : orthodontic, psychological or psychiatric expenses paid for the above-listed child(ren) shall be made to the party making direct payment to the provider for such expenses at the address set Defendant(s) : . . . . . . . forth .below . . . each. party. respectively, .or. as .otherwise advised by the party entitled to payment. . . . . . . . . . for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The insurer that provides the health insurance coverage for the children may continue making payments for medical, optical, hospital, dental, or prescription services directly to any health care provider OF NEW YORK THE PEOPLE OF THE STATEin accordance with the applicable health insurance or health care policy, contract, or plan. TO NOTICES TO OBLIGOR, OBLIGEE, EMPLOYER, INSURANCE COMPANY Pursuant to O.R.C. §3119.47, this order is binding upon the obligor and obligee, their employers, and any insurer that provides health insurance coverage for them or their children. GREETINGS: If the obligor or obligee fails to obtain health insurance coverage for the child(ren) or to WE COMMAND YOU, that this order, and excuses being laid aside, issue an order you attend before comply with requirements inall business the Court immediately shall you and each of to the employer of the the Honorable obligor or obligee, upon written notice from the C.S.E.A., requiring the employer to take , at the Court whatever action is necessary to make application to enroll the obligor or obligee in any available located at County of the child(ren) who are in room health insurance or healthof , on the day care policy, ,contract at plan with coverage for noon, and at any recessed 20 , or o'clock in the the subject of the childgive evidence as towitness in this action on the part of the the insurer at the time support order, a submit a copy of the Court order to or adjourned date, to testify and that the employer makes application to enroll the child(ren) and, if the obligor or obligee’s application is accepted, to deduct any additional amount form the obligor’s or obligee’s earnings necessary to pay any additional cost for that health insurance coverage. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to During the time that this order is in effect, and after the employer has received a copy of the party on order, the employer of the was issued obligee who is the subject of the order shall comply with a this whose behalf this subpoena obligor or for a maximum penalty of $50 and all damages sustained as result of the order and,comply. your failure to upon written request from the other party or agency, shall release to the other party and the C.S.E.A. all information about the obligor’s or obligee’s health insurance coverage that isWitness, Honorable necessary to ensure compliance with O.R.C. §3119.30 et one ofor any order issued under , seq the Justices of the thereunder, County, but not limited to, the name and address of the insurer and any policy, including, day of Court in , 20 contract or plan number. Any information provided by an employer pursuant to this division shall be used only for the purpose of the enforcement of an order issued under O.R.C. §3119.30. Any employer who receives a copy of an order issued under O.R.C. §3119.30 shall notify (Attorney must sign above and type name below) the C.S.E.A. of any change in or the termination of the obligor’s or obligee’s health insurance coverage that is maintained pursuant to an order issued by this section. Attorney(s) for Any insurer that receives a copy of an order issued under O.R.C. §3119.30 shall comply with that section, and with any order issued under that section regardless of the residence of the child(ren). An insurer which provides health insurance coverage in accordance with an order issued under O.R.C. §3119.30 shall reimburse the parentOfficeis designated to receive reimbursement who and P.O. Address Telephone No.: Facsimile No.: 4 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA in this order for covered out-of-pocket medical, optical, hospital, dental, or prescription expenses -against: incurred on behalf of the child(ren) subject to the order. : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .COMMON PLEAS JUDGE . Prepared By: __________________________ THE PEOPLE OF THE STATE OF NEW YORK Approved by: TO Magistrate GREETINGS: CLERK'S CERTIFICATION WE COMMAND YOU, that all business andwere served uponaside, you and each of you attend before I certify that copies of this ORDER excuses being laid the following persons on this _____ , the Honorable at the Court day located 20_____. County of of __________________,at in room , on the day of , 20 , at o'clock in the noon, and at any recessed OBLIGEE NAME AND ADDRESS: OBLIGOR NAME AND ADDRESS: or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to OBLIGEE'S EMPLOYER'S NAME was issued for OBLIGOR'S EMPLOYER'S NAME AND ADDRESS: the party on whose behalf this subpoenaAND ADDRESS: a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of OBLIGEE'S INSURER'S NAME AND ADDRESS: , 20 OBLIGOR'S INSURER'S NAME AND ADDRESS: (Attorney must sign above and type name below) Attorney(s) for DEPUTY CLERK Office and P.O. Address REVISED 9/19/03 Telephone No.: Facsimile No.: 5 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com