CHILD SUPPORT WITH PRIVATE MEDICAL INSURANCE 1. Private insurance is accessible and 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). (Mother or Father) shall continue to pay $ in current support, per month, for all months during which private health insurance is provided. If, and when private health insurance is no longer provided by the party ordered to provide insurance, (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. In the event that private health insurance is no longer provided by the party ord ered to provide insurance, (Mother=s or Father=s) current child support shall change to $ 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. 4. The AObligor@ is the person paying child support and/or cash medical support, and the AObligee@ is the person receiving child support and/or cash medical support. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 5. The Obligor=s obligation to pay cash medical support shall commence the first day of the month immediately following the month in which private insurance is unavailable or terminates. The 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 resumed for the minor child/ren by the party obligated to provide insurance herein. Any cash medical support paid, as set forth above, shall be paid by the Obligor to the 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. 6. The Obligor=s monthly order shall be as follows: When health insurance is provided by the party ordered herein: Current support including 2% processing fee . Cash Medical Support plus 2% processing fee -0.00 Support Arrearage plus 2% processing fee . Total Monthly Order . When health insurance is NOT provided by the party ordered herein: Current support including 2% processing fee . Cash Medical Support plus 2% processing fee . Support Arrearage plus 2% processing fee . Total Monthly Order . 7. Child support and cash medical support shall be paid by means of a wage withholding order through Ohio Child Support Payment Central (ACSPC@). Until the withholding order goes into effect, the Obligor shall pay said support directly to CSPC, as set forth below. Any payments made directly to the 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 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com number must be on the payment. 8. 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. 9. 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. 10. 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. 11. 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 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 INSTITUTIONS; AND ANY OTHER ACTION PERMITTED BY LAW TO OBTAIN MONEY FROM YOU TO SATISFY YOUR SUPPORT OBLIGATION. (RC 3121.29) 12. Within thirty days from the date of this order, (parent/s providing medical insurance) shall designate (names and dates of birth) as dependent/s eligible for health insurance coverage in the group health insurance policy offered (I) by (parent/s providing medical insurance) employer or (ii) through another group health care policy, contract, or available plan, which insurer is (list insurer=s name and policy number). shall supply (other parent) with (I) information regarding the benefits, limitations, and exclusions of the coverage, (ii) insurance forms necessary to receive reimbursement, payment, or other benefits, and (iii) any necessary insurance cards within thirty days of the issuance of this order. (parent/s providing medical insurance) The health plan administrator that provides the health insurance coverage for the child/ren may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract, or plan. shall be responsible for the first $100 per year per child of any medical, dental, orthodontic, 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 (Mother or Father) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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. (parent/s providing insurance) shall incurred for the child/ren as a result of this order. be liable to the other parent for any medical expenses (parent/s providing insurance) failure to comply with Mother and Father shall comply with RC 3119.30 through 3119.58. If (parent/s providing insurance) obtains new employment Clermont County CSE shall comply with the requirements of RC 3119.34 which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child/ren in health care insurance coverage provided by the new employer. (parent/s providing insurance) shall immediately notify the other parent and Clermont County CSE if her health insurance coverage through the above-named insurer is changed or terminated for any reason. 13. 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 a copy of a 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-407 Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com