DR 716 Eff. 1/07 Rev. 10/08 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Judge Sharon L. Kennedy Judge Eva D. Kessler ______________________________________ Plaintiff/1st Petitioner/Petitioner ______________________________________ : Case No_____________________________ : Address ______________________________________ ______________________________________ Telephone ______________________________________ DOB : Magistrate __________________________ : : vs./-and: _______________________________________ Defendant/2nd Petitioner/Respondent _______________________________________ Address ______________________________________ Telephone ______________________________________ DOB : AGREED ENTRY FINAL APPEALABLE ORDER (No Hearing Required) : : : ::::: This is an agreed entry regarding modification of child support and the agreed amount is in compliance with Ohio child support guidelines. No hearing is required. This is an agreed entry regarding modification of health insurance responsibilities for the below listed children and the parties have also calculated child support pursuant to ORC 3119.01-3119.02, 3319.29-3319.32. The parties agree that the amount is in compliance with the Ohio Child Support Guidelines. No hearing is required. This is an agreed entry modifying the prior shared parenting plan to change the parent designated as residential parent for school purposes only. No hearing is required. This is an agreed entry for restoration of a maiden name to _______________________________. No hearing is required. The following are the children of the parties: Name________________________ D.O.B:________ Name ________________________ D.O.B:________ Name ________________________ D.O.B:________ Name ________________________ D.O.B:________ This AGREED ENTRY applies to: All of the above children or Only these children: _____________________________________ _____________________________________ _____________________________________ American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com THE PARTIES AGREE AS FOLLOWS (Please check all that apply): Shared Parenting: The parties have shared parenting of their child(ren) and __________________________________________ (name of parent) shall be designated the residential parent for school purposes. Child Support: The support order does not change OR The support order is hereby amended pursuant to O.R.C. (Ohio Revised Code) 3119.021 as follows (worksheet is attached): Mother/Father shall pay child support as follows: The current Support Order shall be: $ monthly, to be paid in the following manner: per on child support ($ per month, per child), plus $ per on spousal support, plus $ $ per on _________________________________ and Support Arrears Order shall be: The prior order regarding the payment of arrears shall remain the same ($_________ per ___________); OR Obligor shall pay the arrears at a rate of 20% of the current order ($_________ per __________); OR Obligor shall pay the sum of $ _______ per __________on support arrears. Arrears are $_________due obligee, $__________ due State of Ohio, and CSEA processing charge arrears of , $______________ as of plus 2% CSEA processing fee for a total deduction of $ Arrears are preserved; waived; OR per effective . offset against new support order. Health Insurance Coverage (check one): Mother/Father shall provide the primary health insurance for the parties’ minor child(ren). Mother/Father shall provide the primary health insurance for the parties’ minor child(ren). Mother/Father shall provide the secondary health insurance for the parties’ minor child(ren). Each parent shall provide health insurance for the child(ren) whenever it is available through their employment at a reasonable cost. The parties shall divide all uncovered health care expenses as follows: Father shall pay _______% and Mother shall pay _________%. NOTE: THE FOLLOWING LANGUAGE APPLIES TO ALL PARENTING ORDERS: IT IS FURTHER ORDERED 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 a child reaches nineteen years of age unless the order provides that the duty of support continues under circumstances described 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. American LegalNet, Inc. www.FormsWorkflow.com 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.” 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 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. The agreed entry shall specifically identify the deduction order to be issued. If the obligor is receiving income from a payor as defined in section 3121.01(E) of the Revised Code, an income withholding notice shall issue. If the obligor’s income is not subject to withholding, a bank account deduction notice shall issue. If the obligor has no income, but is able to post bond, an order to post bond shall issue. If the obligor is unemployed and has no funds from which support can be paid, an order to seek work shall issue and the obligor shall pay the current statutory minimum support order (currently $50.00 per month for all children subject to the order). The court may waive or modify the minimum order in appropriate circumstances. The agreed entry shall specify any child(ren) that either parent shall be entitled to claim as dependent(s) for federal income tax purposes. The agreed entry shall also specify the tax year(s) for which the child(ren) may be claimed as dependent(s), the name of American LegalNet, Inc. www.FormsWorkflow.com the person who may claim them and the requirement that the person claiming them 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(ren) are to be claimed as dependent(s), on or before January 31st of the following year. (ORC 3119.82) IT IS FURTHER ORDERED that the parties must comply with one of the following obligations concerning health insurance coverage imposed under section 3119.30 to 3119.31 of the Ohio Revised Code no later than thirty (30) days after the applicable order is issued: If one of the parties has health insurance: “Mother/Father shall provide the primary health insurance for the parties’ minor child(ren). Mother/Father shall provide Mother/Father with all current health insurance information, including but not limited to, insurance cards. In the future, Mother/Father, upon receipt, shall provide all updated insurance information and cards to Mother/Father within fourteen (14) days. The parties shall divide all 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 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: “Mother/Father shall provide the primary health insurance for the parties minor child(ren). Mother/Father shall provide the secondary health insurance for the parties’ minor child(ren). Each party shall provide the other party with all current health insurance information, including but not limited to, insurance cards. In the future, the parties, upon receipt, shall provide all updated insurance information and cards to each other within fourteen (14) days. The parties shall divide all 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 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.” American LegalNet, Inc. www.FormsWorkflow.com If neither of the parties has health insurance: “Each parent shall provide health insurance for the child(ren) whenever it is available through their employment at a reasonable cost. In the event a parent obtains health insurance, the insured parent shall provide the other parent with all current health insurance information, including but not limited to, insurance cards. In the future, the insured parent, upon receipt, shall provide all updated insurance information and cards to the other parent within fourteen (14) days. The parties shall divide all 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 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 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.” A DR705 health insurance order shall be issued if either, or both, parents have health insurance available to them through a group policy. A DR707 health insurance order shall be issued 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. A DR708 health insurance order shall be issued if neither parent has health insurance available through a group policy, but one or both has the means of providing private insurance 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. The agreed entry shall further state that if the obligor is found in contempt for failing to provide health insurance coverage and he/she has previously been found in contempt under Chapter 2705 of the Ohio 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 Ohio Revised Code 3119.30 to 3119.31. IT IS FURTHER ORDERED that any person who is the residential parent of a child, including any party to a shared parenting agreed entry an any other legal custodian, shall send a notice of intent to relocate to the Domestic Relations Court Case Management Office, as follows: (A) If a parent or other legal custodian desires to move, he/she must notify, in writing: 1. The other parent; 2. The Domestic Relations Court Compliance Office; and 3. The Butler County Child Support Enforcement Agency (CSEA.) (B) Notice must be sent within the following time frames: 1. If relocating within Butler County - at least thirty (30) days in advance of the move. 2. If relocating outside Butler County - at least sixty (60) days in advance of the move. (C) Written notice must be submitted to the Case Management Office on form C13, if relocating within Butler County, and on form C13-A, if relocating outside Butler County. (D) 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 parenting time. American LegalNet, Inc. www.FormsWorkflow.com (E) 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 41 (B). 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, or an order limiting a parent’s access to specific areas. Any order limiting a parent’s access shall contain specific findings of fact which support such limitation. The order shall contain a notice to school and day care officials and to all keepers of records that their knowing failure to comply with the order may be punishable as contempt of court. The parties in the above-captioned matter hereby waive the necessity of the Magistrate’s making findings of fact and issuing a decision, and further waive the time period for filing objections to said decision as provided by Ohio Civil Rule 53, and consent to the immediate filing of a Judgment Entry in this matter, service of which is hereby acknowledged and waived. THE PARTIES AND THEIR LEGAL COUNSEL, IF REPRESENTED, APPROVE THE FORGOING AGREEMENT BY THEIR SIGNATURES BELOW: ________________________________________ Plaintiff/1st Petitioner/Petitioner Telephone # _______________________________ _________________________________________ Defendant/2nd Petitioner /Respondent Telephone#________________________________ Sworn to and subscribed in my presence by Plaintiff/First Petitioner/Petitioner___________________________________________ on _________________, 20____. ______________________________________________ NOTARY PUBLIC Sworn to and subscribed in my presence by Defendant/Second Petitioner/Respondent_________________________________ on _________________, 20____. ______________________________________________ NOTARY PUBLIC __________________________________ Attorney for Plaintiff/1st Petitioner/Petitioner Supreme Court Reg. #________________ Address: __________________________ Telephone #_______________________ __________________________________ Attorney for Defendant/2nd Petitioner/Respondent Supreme Court Reg. #_________________ Address____________________________ Telephone# _________________________ I find that the parties have freely and voluntarily entered into the above agreement and that this agreement has been signed and approved by the parties and their attorneys. The agreement is found to be fair and just to all parties and is in the best interest of the children. I recommend that the agreement be approved and that the agreement become the order of this court. ___________________ Date ___________________ Date __________________________________________ Magistrate __________________________________________ Judge American LegalNet, Inc. www.FormsWorkflow.com NOTICE OF RIGHTS TO APPEAL The filing of timely written objections by any party to this action shall act as an automatic stay of the above judgment entry until the Court takes further action as delineated in Civil Rule 53. INTERIM ORDERS, HOWEVER, ARE NOT SUBJECT TO THIS AUTOMATIC STAY, AND SHALL REMAIN IN EFFECT REGARDLESS OF THE FILING OF OBJECTIONS. OBJECTIONS MUST BE FILED WITHIN FOURTEEN (14) DAYS OF THE FILING OF THIS MAGISTRATE’S DECISION OR AMENDED MAGISTRATE’S DECISION. Objections must be in writing, must be specific and state with particularity the grounds of the objection. For other requirements, see Civil Rule 53 and Local Rule. PARTIES WAIVE THEIR RIGHT TO OBJECT WITHIN 14 DAYS American LegalNet, Inc. www.FormsWorkflow.com