CHILD SUPPORT WITH NO PRIVATE MEDICAL INSURANCE 1. Private insurance is not accessible and/or reasonable in cost. Effective (date), (Mother or Father) shall pay current child support in the amount of $ per month ($ per month, per child) plus a two percent processing fee, for a total of $ per month ($ per week) , and (Mother or Father) shall pay cash medical support in the amount of $ per month, plus a two percent processing fee, for a total of $ per month ($ per week). Cash medical support shall be paid in addition to any current child support and arrearage. (Mother or Father) shall continue to pay $ in current support, per month, and $ in cash medical support, per month, for all months during which private health insurance is not provided. If, and when private health insurance is provided by either parent, (Mother’s or Father’s) current child support shall change, as set forth below. Check this box if the child support order is a deviation from the actual annual obligation on the support worksheet: G The above child support deviates from the actual annual obligation on the child support worksheet because, pursuant to RC 3119.22, the actual annual obligation is unjust, inappropriate and not in the best interest of the child/ren for the following reason(s): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 2. Any credit or arrearage which may be reflected on the CSEA records as of (date) shall be preserved. OR Due to the effective date, there will be an arrearage. (Mother or Father) shall pay the arrearage at the rate of $ per month, plus a two percent processing fee, for a total monthly payment of $ ($ per week). No Federal or State Aid is involved and, if there is Federal or State Aid involved, this entry shall not operate as a bar to any government agency collecting funds due. 3. The “Obligor” is the person paying child support and/or cash medical support, and the “Obligee” is the person receiving child support and/or cash medical support. 4. Obligor’s obligation to pay cash medical support shall cease on the last day of the month immediately preceding the month in which private health insurance is provided for the minor child/ren by either party. Obligor’s obligation to pay cash medical support shall resume on the first day of the month immediately following the month in which private insurance is unavailable or terminates. Any cash medical support paid, as set forth above, shall be paid by Obligor to Obligee if the child is not a Medicaid/CareSource recipient, or to CSE to defray the cost of Medicaid/CareSource expenditures if the child is a Medicaid/CareSource recipient. When Obligor’s cash medical support obligation is not in effect, Obligor shall pay revised American LegalNet, Inc. www.FormsWorkFlow.com current child support in the amount of $ a two percent processing fee, for a total of $ per month ($ per month ($ per month, per child), plus per week). 6. Obligor’s monthly order shall be as follows: When health insurance is provided: Current support including 2% processing fee Cash Medical Support plus 2% processing fee Support Arrearage plus 2% processing fee Total Monthly Order _____ -0.00 _____ _____ When health insurance is NOT provided: Current support including 2% processing fee Cash Medical Support plus 2% processing fee Support Arrearage plus 2% processing fee Total Monthly Order 5. _____ _____ _____ _____ Child support and cash medical support shall be paid by means of a wage withholding order through Ohio Child Support Payment Central (“CSPC”). Until the withholding order goes into effect, Obligor shall pay said support directly to CSPC, as set forth below. Any payments made directly to Obligee shall be deemed a gift and not in satisfaction of said support. A child support worksheet is attached hereto and incorporated herein. Support shall terminate when the child reaches the age of 18 if the child no longer attends an accredited high school on a full-time basis; the child ceases to attend an accredited high school on a full-time basis after attaining the age of majority; or the child’s death, marriage, emancipation, or enlistment in the armed services. The support shall continue after the child reaches the age of 18 years as long as the child continuously attends on a full-time basis any recognized and accredited high school, but shall not continue past the date the child reaches the age of 19 years. RC 3119.86 Payments to Ohio CSPC should be sent to the following address: Ohio CSPC, P. O. Box 182372, Columbus, Ohio 43218-2372. Payment may be made by personal check, certified check, cashier’s check or money order only. Payments must include the court case number and the SETS number; if the SETS number is not available, then the Payor’s Social Security number must be on the payment. 7. Regardless of the frequency or amount of the support payments to be made under this order, the CSEA shall administer the order on a monthly basis. Payments under the order are to be made in the manner ordered by the Court and, if the payments are to be made other than on a monthly basis, the required monthly administration by the agency does not affect the frequency or the amount of the support payments to be made under the order. Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 8. All child support, cash medical support and spousal support ordered by this order shall be withheld or deducted from the wages or assets of the Obligor under the order in accordance with RC 3121.02 and shall be forwarded to the Obligee under the order. The specific withholding or deduction requirements or other appropriate requirements to be used to collect the support shall be set forth in and determined by reference to the notices that are mailed by the court or child support enforcement agency or the court orders that are issued and mailed, and shall be determined without the need for any amendment to the support order. Those notices and court orders, plus the notices provided by the court or agency that require the person who is required to pay the support to notify the child support enforcement agency of any change in his employment status or of any other change in the status of his assets, are final and are enforceable by the court. RC Chapter 3121. 9. The Obligee immediately shall notify, and the Obligor may notify, the child support enforcement agency of any reason for which the support order should terminate, including but not limited to, the child’s attainment of the age of majority if the child no longer attends an accredited high school on a full-time basis and the support order does not provide for the duty of support to continue past the age of majority; the child ceasing to attend such a high school on a full-time basis after attaining the age of majority, if the support order does not provide for the duty of support to continue past the age of majority; or the death, marriage, emancipation, enlistment in the armed services, deportation, or change of legal or physical custody of the child. A willful failure to notify the child support enforcement agency as required, as stated above, is contempt of court. RC 3119.87 to 3119.90. 10. 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 FOR A FIRST OFFENSE, $100 FOR A SECOND OFFENSE, AND $500 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 AND IMPRISONMENT FOR NOT MORE THAN 90 DAYS. IF YOU ARE AN OBLIGOR AND YOU FAIL TO MAKE THE REQUIRED NOTIFICATIONS, YOU MAY NOT RECEIVE NOTICE OF THE FOLLOWING ENFORCEMENT ACTIONS 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 American LegalNet, Inc. www.FormsWorkFlow.com INSTITUTIONS; AND ANY OTHER ACTION PERMITTED BY LAW TO OBTAIN MONEY FROM YOU TO SATISFY YOUR SUPPORT OBLIGATION. (RC 3121.29) 11. Neither party presently has health insurance available for the benefit of the minor child/ren. Each party shall immediately inform the other party and Clermont County CSE if health insurance coverage for the child/ren becomes available at a reasonable cost through a group health insurance policy offered by his/her employer or through any other group health care policy, contract, or plan available to either party. If CSEA determines that the cost is reasonable, or the Court determines that the cost is reasonable in a motion pending before the court, then that parent shall provide the health insurance. Mother and Father shall then comply with ORC 3119.30 through 3119.58. shall be responsible for the first $100 per year per child of any medical, dental, orthodontal, optical, prescription, psychiatric, psychological, or counseling expenses not paid by insurance, including deductibles and/or co-payments under the health insurance plan for the children. Any additional such expenses shall be divided between the parties in amounts equal to their percentage of total income as found in the child support worksheet as follows: Mother shall pay percent and Father shall pay percent. However, in the event Obligee has actually received cash medical support payments from Obligor in a particular year, then Obligor shall receive credit for ____ percent (same percent as his/her portion of uncovered expenses) of any cash medical payments actually received by Obligee before Obligor is required to make any additional payments for medical expenses. (Mother or Father) 12. Each party shall submit to the other party copies of all medical bills and receipts for payment as soon as each party is in receipt of the bill/receipt. Each party shall submit copies of all bills (including expenses for which the submitting parent is responsible) so the other party is aware of what expenses have been incurred and what has been paid; i.e., each parent should have a complete set of all the medical bills and receipts. Proof of payment shall be limited to a receipt for payment signed by the medical provider, a copy of a cancelled check or credit card statement verifying the amount paid. Each party shall reimburse the other party for his/her portion within 30 days of the date he/she receives the receipts. In the event either parent later receives any form of refund from the medical insurance company, or any other agency, of the amount paid by either parent to the medical provider, the parent receiving the refund shall reimburse the other parent with his/her share of the refund within thirty days of receipt of the refund. Neither party shall use the child/ren to deliver medical bills, proof of payment, or reimbursement to the other party. Rev. 3/2010 Form DR-408 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com