COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO ___________________________________ DEFENDANT-1 : CASE NO. _____________________________ : JUDGE ________________________________ and : ___________________________________ DEFENDANT-2 JUDGMENT ENTRY : This cause came on for hearing on _____________________ , 20______, and was duly heard before the Honorable ________________________, Judge of the Domestic Relations Division of the Court of Common Pleas, upon the Petition of the parties and the evidence. Upon due consideration thereof, the Court finds one/both of the parties was a resident/were residents of the State of Ohio for more than six (6) months immediately preceding the filing of the Petition; they were married as alleged; and ________ child(ren) was/were born as issue of the marriage, to wit: (names and birth dates) ___________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________. The Court further finds the Petition for Dissolution of Marriage was filed on ______________, 20_____; service was waived/perfected thereon pursuant to law, and attached thereto was a separation agreement signed by the parties which is fair, just and equitable. The Court further finds, in open Court this date, the parties acknowledged they were still in agreement as to the terms thereof and there has been a full disclosure by each of the parties of all of his or her assets. The Court further finds a copy of said agreement is attached hereto, marked as Exhibit “A” and is incorporated herein as if fully rewritten. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the marriage contract heretofore existing between the parties be and is hereby dissolved and set aside and that the terms of the attached separation agreement be and are ordered into execution. ALLOCATION OF PARENTAL RIGHTS AND RESPONSIBILITIES FOR THE CARE OF THE CHILD(REN) (Check appropriate box and cross out alternative language) The Court has reviewed the plan the parties previously filed for the exercise of shared parenting in accordance with Ohio Revised Code §3105.65(B) and Ohio Revised Code §3109.04(D)(1)(a) and determines that the plan is in the best interest of the child(ren). OR DR0706126 Dissolution by Judge.doc American LegalNet, Inc. www.FormsWorkflow.com The Court finds that the parents have waived the requirement of a written request for shared parenting and plan for shared parenting filed at least 30 days before hearing. The Court finds that the parents have agreed to shared parenting and have jointly submitted a plan on the date of hearing which plan the Court finds is in the best interest of the child(ren). IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that this Judgment Entry shall constitute an ORDER FOR SHARED PARENTING pursuant to Ohio Revised Code §3109.04(A), (D) and (G) and the parties shall share the rights and responsibilities for the care of the child(ren) in accordance with the attached approved shared parenting plan which is adopted and incorporated herein by reference. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that each parent is to file a notice of intent to relocate if he or she intends to move to a residence other than the one specified in this order. Pursuant to the determination made under Ohio Revised Code §3109.051(G)(2) and subject to further order of the Court, the other parent shall be sent a copy of any notice of relocation filed with the Court. OR IT IS FURTHER ORDERED, ADJUDGED AND DECREED that parental rights and responsibilities are allocated primarily to ________________________ who is hereby designated the residential parent and legal custodian of the minor child(ren). The parent who is not the residential parent, ________________________, shall have parenting time in accordance with the schedule set forth in the parties’ separation agreement attached hereto/in accordance with the Standard Visitation Guidelines attached hereto as Exhibit ________ and incorporated herein by reference. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the residential parent is to file a notice of intent to relocate if he/she intends to move to a residence other than the one specified in this order. Pursuant to the determination made under Ohio Revised Code §3109.051(G)(2) and subject to further order of the Court, the parent who is not the residential parent shall/shall not be sent a copy of any notice of relocation filed with the Court. FOR ALL ORDERS IT IS FURTHER ORDERED, ADJUDGED AND DECREED that __________________ _______________ shall pay to ________________________ the sum of $____________, which sum includes 2% processing charge, per month for the support of the minor child(ren) ($____________ per month per child). Said order shall continue until further order of Court or until said child(ren) reach(es) age 18 or so long as the child(ren) continuously attend(s), on a full-time basis, any recognized and accredited high school, however, no later than age 19. Attached hereto as Exhibit ________ is the worksheet used in computing the child support under Ohio Revised Code §3119.022 or 3119.023. In addition, ________________________ shall pay to _______________________ the sum of $____________, which sum includes 2% processing charge, per month as spousal support in accordance with the terms set forth in the attached separation agreement/subject to the death of either party or the remarriage of the spouse receiving spousal support . The total amount of $____________ per month, which sum includes 2% processing charge, shall be paid through the Ohio Child Support Payment Central (CSPC). Any payments not made through CSPC shall not be considered as payment of support. Said support shall be secured by means of a support withholding or deduction notice to Obligor’s income source/order to post bond/order to report. 2 American LegalNet, Inc. www.FormsWorkflow.com INCOME SOURCE: ADDRESS: _________________________________________ _________________________________________ _________________________________________ 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 order issued in accordance with Chapters 3119, 3121, 3123, and 3125 of the Revised Code or a withdrawal directive issued pursuant to §3123.24 to 3123.38 of the Revised Code and shall be forwarded to the obligee in accordance with Chapters 3119, 3121, 3123, and 3125 of the Revised Code. The following group health insurance and health care policies, contracts, and plans are available at a reasonable cost to Obligor or Obligee (list name of insurer and to whom available): Insurer: _____________________________________________ _____________________________________________ _____________________________________________ Available to: ______________________________ ______________________________ ______________________________ CHOOSE ONE OF THE THREE ALTERNATIVES (Check appropriate box) ALTERNATIVE ONE The Court finds that Obligor/Obligee has health insurance available at a reasonable cost through a group health insurance or health care policy, contract or plan offered through Obligor’s/Obligee’s employer or through another group health insurance or health care policy, contract or plan. The health insurance coverage is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to Obligor/Obligee. OR ALTERNATIVE TWO The Court finds that health insurance coverage is available at a reasonable cost to both Obligor and Obligee and that dual coverage by both parents would provide for coordination of medical benefits without unnecessary duplication of coverage. APPLICABLE TO ALTERNATIVES ONE AND TWO IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that Obligor/Obligee/both Obligor and Obligee is/are ordered to obtain health insurance coverage through (name and address of employer, the name and address of the group health plan, policy or contract number; and group number) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that health insurance coverage be obtained for the following child(ren) and that the child(ren) be designated as covered dependents under any health insurance or health care policy, contract or plan: 3 American LegalNet, Inc. www.FormsWorkflow.com Full Name of Each Child ___________________________ ___________________________ ___________________________ ___________________________ Address _________________________________ _________________________________ _________________________________ _________________________________ Date of Birth ____________ ____________ ____________ ____________ IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the party ordered to provide health insurance supply the other party with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment of other benefits under the health insurance coverage and a copy of any necessary insurance cards. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor/Obligee pay the reasonable and ordinary uninsured and unreimbursed medical, dental, optical and prescription drug expenses for the minor child(ren) which are defined pursuant to Ohio Revised Code §3119.01(C )(4) as the first $100 per child per calendar year of the above expenses. Any remaining uninsured and/or unreimbursed medical, dental, optical and prescription drug expenses including co-payments and/or deductibles shall be paid by Obligor/Obligee/both Obligor and Obligee (1) in amounts equal to the percentages indicated on Line 16 of the Child Support Computation Worksheet or (2) in accordance with the following formula: _________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the health insurer shall reimburse (name, address and telephone number) ____________________________________________ ____________________________________________________________________________________ for out-of-pocket medical, hospital, dental, optical or prescription expenses paid for the following child(ren): ___________________________________________________________________________ ____________________________________________________________________________________. If the person required to obtain health care insurance coverage for the child(ren) subject to this child support order obtains new employment and the health insurance coverage for the child(ren) is provided through the previous employer, CSEA shall comply with the requirements of Ohio Revised Code §3119.43 and 3119.44 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. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor/Obligee submit a copy of this order to the insurer at the time application is made to enroll the child(ren) and that Obligor/Obligee, no later than 30 days after the issuance of this order, furnish written proof to CSEA that the foregoing orders have been satisfied. If the person required to obtain health insurance coverage pursuant to this order for the child(ren) fails to obtain health insurance coverage, CSEA shall comply with Ohio Revised Code §3119.40 and 3119.41 to obtain a court order requiring Obligor or Obligee to obtain the health insurance coverage. The insurer that provides the health insurance coverage for the child(ren) may continue making payments for medical, optical, hospital, dental or prescription services directly to any health care provider in accordance with the applicable health insurance or health care policy, contract or plan. 4 American LegalNet, Inc. www.FormsWorkflow.com Any insurer that receives a copy of an order or notice described in Ohio Revised Code §3119.30, 3119.41 or 3119.44 shall comply with it in accordance with §3119.30 to 3119.58, regardless of the residence of the child(ren). The employer of the party required to obtain health insurance coverage is required to release to the other parent or CSEA, upon written request, any necessary information on the health insurance coverage including, but not limited to, the name and address of the insurer and any policy, contract or plan number, and otherwise comply with Ohio Revised Code §3119.30 et. seq. and any court order or notice described in these sections. Any employer who receives a copy of an order or notice issued under Ohio Revised Code §3119.30, 3119.41 or 3119.44 shall notify CSEA of any change in or the termination of Obligor’s or Obligee’s health insurance coverage that is maintained pursuant to the order or notice. OR ALTERNATIVE THREE The Court finds that neither party has health insurance for the child(ren) available to them at a reasonable cost either through a group health insurance or health care policy, contract or plan offered by an employer or through any other group health insurance or health care policy, contract or plan. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that Obligee/ Obligor pay the reasonable and ordinary medical, dental, optical and prescription drug expenses for the minor child(ren) which are defined pursuant to Ohio Revised Code §3119.01(C) (4) as the first $100 per child per calendar year of the above expenses, after which Obligor and Obligee share liability for the cost of the medical and health care needs of the child(ren) (1) in amounts equal to the percentages indicated on Line 16 of the Child Support Computation Worksheet or (2) in accordance with the following formula: ____________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor and Obligee immediately inform the Court if health insurance coverage for the child(ren) becomes available at a reasonable cost through a group health insurance or health care policy, contract or plan offered by Obligor’s or Obligee’s employer or through any other group health insurance or health care policy, contract or plan available to Obligor or Obligee. APPLICABLE TO ALL ORDERS IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor immediately notify CSEA, in writing, of the commencement of any change in employment (including self-employment), receipt of additional income/monies or termination of benefits. Obligor shall include a description of the nature of the employment/income and the name, business address and telephone number of any income source/employer. Obligor shall immediately notify the CSEA of any change in the status of an account from which support is being deducted or the opening of an new account with any financial institution along with the name, business address and account number(s). IT IS FURTHER ORDERED, ADJUDGED AND DECREED that all parties comply with the request of CSEA or the Court to provide information regarding his/her health insurance benefits, federal income tax return from the previous year, all pay stubs within the preceding six (6) months, all other records evidencing the receipt of any other salary, wages or compensation within the preceding six (6) 5 American LegalNet, Inc. www.FormsWorkflow.com months. Said records include, but are not limited to, proof of unemployment status, financial institution accounts and any benefits (i.e., unemployment, sub pay, sick leave, Workers Compensation, severance pay, retirement, disability, or annuities, Social Security and Veteran’s Administration). Either party’s failure to provide any income/benefits information pursuant to this order, or failure to comply with the foregoing order of notification shall be considered contempt of court, punishable by a fine and/or jail sentence. Attorney fees and court costs may then be assessed against the party held in contempt. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the residential parent and legal custodian of the minor child(ren) immediately notify the CSEA of any reason for which the support order should terminate including, but not limited to, death, marriage, emancipation, high school completion/termination, enlistment in armed services, deportation or change of legal custody of the child(ren). The following information is provided for the use of Cuyahoga Support Enforcement Agency (CSEA) in accordance with §3121.24 of the Ohio Revised Code: OBLIGEE: NAME: RESIDENCE ADDRESS: _______________________________________ _______________________________________ _______________________________________ MAILING ADDRESS: _______________________________________ _______________________________________ RESIDENTIAL PHONE NO.: _______________________________________ SOCIAL SECURITY NO.: _______________________________________ DATE OF BIRTH: _______________________________________ DRIVER’S LICENSE NO.: _______________________________________ OBLIGOR: NAME: RESIDENCE ADDRESS: _______________________________________ _______________________________________ _______________________________________ MAILING ADDRESS: _______________________________________ _______________________________________ RESIDENTIAL PHONE NO.: _______________________________________ SOCIAL SECURITY NO.: _______________________________________ DATE OF BIRTH: _______________________________________ DRIVER’S LICENSE NO.: _______________________________________ 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 OR AGENCY, WHICHEVER ISSUED THE SUPPORT ORDER. IF YOU ARE THE OBLIGOR UNDER A CHILD SUPPORT ORDER AND YOU FAIL TO MAKE THE REQUIRED NOTIFICATION, 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 ISSUED BY A COURT AND YOU WILLFULLY FAIL TO GIVE THE REQUIRED NOTICES, YOU MAY BE FOUND IN CONTEMPT OF COURT AND BE 6 American LegalNet, Inc. www.FormsWorkflow.com SUBJECTED TO FINES OF UP TO $1000 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. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that any Qualified Domestic Relations Order (QDRO) or Division of Property Order that is ordered herein shall be prepared by the party noted in Local Rule 28(E)(1) of the Court of Common Pleas, Division of Domestic Relations, Cuyahoga County, Ohio or ___________________________________________________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the ___________________ (DOB: ___________) be and she hereby is restored to her former name of _______________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the ___________________ pay the costs of this proceeding, for which judgment is rendered and execution may issue. IT IS SO ORDERED. _______________________________________ JUDGE Approved by: _______________________________________ Defendant-1/Attorney _______________________________________ Defendant-2/Attorney 7 American LegalNet, Inc. www.FormsWorkflow.com