COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO ________________________________________ PLAINTIFF/PETITIONER-01 : : JUDGE _____________________________ vs. : : ________________________________________ DEFENDANT/PETITIONER-02/RESPONDENT : : MAGISTRATE _______________________ AGREED JUDGMENT ENTRY (CHILD SUPPORT AND MEDICAL SUPPORT) ESTABLISHMENT MODIFICATION CASE NO. ___________________________ This matter came on for hearing on _______________ before Magistrate ___________________, to whom this matter was referred by the Honorable ___________________, Judge of the Domestic Relations Division of the Court of Common Pleas upon the following: ________________________________________________________________________ ________________________________________________________________________ Present were: ______________________________ Plaintiff/Petioner-01 ______________________________ Defendant/Petitioner-02/Respondent ______________________________ Attorney for Plaintiff/Petitioner-01 ______________________________ Attorney for Defendant/Petioner02-Respondent Assistant County Prosecuting Attorney ________________________ on behalf of the Cuyahoga Job and Family Services ­ Office of Child Support Services (CJFS-OCSS). The Court finds that any unrepresented party has been advised of the right to counsel in this proceeding and has voluntarily and knowingly waived said right. The Court further finds that the parties have resolved their differences by agreement, the terms of which are set forth herein. The Court finds that said agreement is fair, just and equitable. The Court further finds that the parties waive any rights under Ohio Civil Rule 53. The Court finds that the parents owe a duty of support for the child(ren) named below: Full name of each child _________________________________________________ _________________________________________________ _________________________________________________ Date of Birth ___________________ ___________________ ___________________ The duty of support shall continue until further order of Court or until said child(ren) reach(es) age 18 or so long as the continuously attend(s), on a full-time basis, any recognized and accredited high school, however, no later than age 19, or as otherwise provided in R.C. §3119.86. The Court finds that: (Check appropriate box) an order for the Child Support Obligor to pay current child support and medical support for the above minor is hereby established. a substantial change of circumstance has occurred and the existing order to pay current support and medical support for the above minor is hereby modified. H810 Agreed Judgment Entry to Modify Child Support (Revised 02/2015) Case No. __________ 1 CHILD(REN)'S HEALTH CARE Uncovered Healthcare Expenses Pursuant to R.C. 3119.30(A), both parents are liable for the health care of the child(ren) who is/are not covered by private health insurance or cash medical support as calculated in accordance with R.C. 3119.022 or 3119.023. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the child support obligor pay __________% and the child support obligee pay __________% of the annual costs of the health care needs of the child(ren) that exceed the amount of cash medical support ordered to be paid, if any, when private health insurance coverage is not available or is not being provided in accordance with this order, OR of the uninsured health care costs or co-payment or deductible cost required under the health insurance policy, contract or plan that covers the child(ren) when private health insurance coverage is being provided in accordance with this order. The following individual shall be reimbursed by the health plan administrator(s) for covered outof-pocket medical, optical, hospital, dental or prescription expenses paid for the child(ren) subject to this order: Name of party _________________________________________ Address _________________________________________ _________________________________________ Telephone number _________________________________________ Private Health Insurance (Check one of the following two boxes) The Court finds that neither party has accessible Private Health Insurance available at a reasonable cost to cover the minor children. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the child support obligor and the child support obligee shall immediately inform the CJFS-OCSS if private health insurance coverage for the child(ren) becomes available to either of them. The CJFS-OCSS shall determine if the private health insurance is available at a reasonable cost and if coverage is reasonable, order the child support obligor or the child support obligee to obtain private health insurance. -OR- The Court finds that Plaintiff has Defendant has both parties have accessible private health insurance available to cover the child(ren) through a group policy, contract or plan. (If the above box is checked, check one of the following two boxes) The Court further finds that the contributing cost (cost of adding the child(ren) to existing of the private health insurance available to Plaintiff and/or the Defendant does not exceed that party's Health Insurance Maximum. coverage or difference between self-only and family coverage) (Check box if applicable) The Court further finds that it is not in the best interest of the child(ren) for the parties to obtain or maintain the private health insurance coverage that does not exceed the parties' respective health insurance maximum because ________________________ _______________________________________________________________________. -OR- H810 Agreed Judgment Entry to Modify Child Support (Revised 02/2015) Case No. __________ 2 The Court further finds that the contributing cost (cost of adding the child(ren) to existing of the private health insurance available to Plaintiff and/or the Defendant exceeds that party's Health Insurance Maximum. coverage or difference between self-only and family coverage) The Court further finds that: (If the above box is checked one of the following boxes must be checked) both parents agree that Plaintiff Defendant both parents shall obtain or maintain private health insurance that exceeds the Health Insurance Maximum for that parent. Plaintiff Defendant has requested to obtain or maintain private health insurance that exceeds the Health Insurance Maximum for that parent. it is in the best interest of the child(ren) for Plaintiff Defendant to obtain