C-15 Eff. 1/1/2015 Rev. 8/23/2016 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO __________ 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 the obligor and child support 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) 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) 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), 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. American LegalNet, Inc. www.FormsWorkFlow.com If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL IMMEDIATELY NOTIFY CSEA AT 513-8873362 AND 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 is not being provided and becomes available to either the obligor or obligee, they SHALL immediately notify the CSEA, at 513-887-3362, that private health insurance coverage for the children has become available to either of them, along with the full name and address of the health insurance company, and the plan type, policy number, group number and effective date of the health insurance. The CSEA shall determine pursuant to ORC 3119.30 (B) (4) if the private health insurance is available at a reasonable cost, and if coverage is reasonable, division (B) (2) or (3) of ORC 3119.30 shall apply. 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 the obligor and child support 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) 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) 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): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 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: American LegalNet, Inc. www.FormsWorkFlow.com 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) 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) 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 medi