H953 (Revised 0/201) 1 Case No. COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO : PETITIONER - 01 : : CaseNo. JUDGE : and : JUDGMENT ENTRY OF DISSOLUTION : (No Children) (With Spousal Support) : PETITIONER - 02 : : 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 Magistrate to whom it was referred by the Honorable , Judge of the Domestic Relations Division of the Court of Common Pleas, upon the Petition of the parties and the evidence. The Court finds that Petitioner-01 was Petitioner-02 was both parties were resident(s) of the State of Ohio for more than six months immediately preceding the filing of the Petition and venue is proper in this county. The parties were married as alleged and there are no minor children of the marriage. The Court further finds that the Petition for Dissolution of Marriage was filed on , service was waived thereon pursuant to law and attached thereto was a Separation Agreement signed by the parties. A copy of the Separation Agreement is attached hereto as Exhibit A and incorporated herein as if fully rewritten. The Court further finds, in open Court this date, the parties acknowledged that they were still in agreement as to the terms thereof and that there has been a full disclosure by each of the parties of all of his or her income, assets and liabilities. The Court further finds that the Separation Agreement is fair, just, and equitable. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the marriage contract heretofore existing between the parties is hereby dissolved and that the terms of the attached Separation Agreement are hereby ordered into execution. SPOUSAL SUPPORT The Court finds, upon considering all of the factors set forth in Ohio Revised Code 2473105.18(C)(1) and in particular those specified below, that it is appropriate and reasonable for Petitioner-01 Petitioner-02 to pay spousal support to Petitioner-01 Petitioner-02. The Court findsthat the following factors support this award: . IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that Petitioner-01 Petitioner-02 shall pay spousal support to Petitioner-01 Petitioner-02 in the sum of $ per month, plus 2% processing charge, for a term of , commencing . The Court shall shall not retain jurisdiction to modify this order. Pursuant to Ohio Revised Code 2473105.18(B), all payments shall terminate upon the death of either party or . American LegalNet, Inc. www.FormsWorkFlow.com H953 (Revised 0/201) 2 Case No. The Court finds that, for purposes of this order Petitioner-01 Petitioner-02 is the spousal support obligor (pays support) and Petitioner-01 Petitioner-02 is the spousal support obligee (receives support). The following information is provided in accordance with 2473105.72 and 2473121.30 of the Ohio Revised Code: SUPPORT OBLIGEE (receives support): Name: Social Security Number: xxx-xx- (fill in last four digits) SUPPORT OBLIGOR (pays support): Name: Social Security Number: xxx-xx- (fill in last four digits) Date of Birth: Temporary Support Arrearage/Overpayment (Check one of the following two boxes) The Court finds that there are no arrearages/overpayments under temporary support orders, including but not limited to: spousal support, child support or cash medical support, and uncovered health care expenses. -OR- The Court finds that as of the temporary support arrearage overpayment is $. (Amount MUST be provided) This sum includes all sums ordered under temporary support orders, including but not limited to: spousal support, child support or cash medical support, and uncovered health care expenses. (If an arrearage finding is made, check one of the following two boxes) IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the support obligor shall pay an additional $ per month toward the existing temporary support arrearage. -OR- IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that judgment is rendered in the amount of $ as and for temporary support arrears in favor of Petitioner-01 Petitioner-02 and against Petitioner-01 Petitioner-02 upon which execution may issue. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that any claims of CCJFS-OCSS for any assigned temporary support arrearage or unpaid processing charges are hereby preserved. Monthly Payment of Support The support obligor shall pay $ per month, plus 2% processing charge, because Private Health Insurance is is not ordered to be provided at this time. This amount includes all applicable child support, spousal support, cash medical support and payment toward arrearage. All support under this order shall be withheld or deducted from the income or assets of the support obligor pursuant to a withholding or deduction notice or appropriate order issued in accordance with American LegalNet, Inc. www.FormsWorkFlow.com H953(Revised /201) Case No. 3 Chapters 3119., 3121., 3123., and 3125. of the Ohio Revised Code or a withdrawal directive issued pursuant to sections 3123.24 to 3123.38 of the Ohio Revised Code and shall be forwarded to the obligee in accordance with Chapters 3119., 3121., 3123., and 3125. of the Ohio Revised Code. Payments shall be made in the manner ordered by the Court. If payments are to be made other than on a monthly basis, the required monthly administration by the CJFS-OCSS does not affect the frequency or the amount of the support payments to be made under the order. All support shall be paid through Ohio Child Support Payment Central (OCSPC), P.O. Box 182372, Columbus, Ohio 43218-2372. Any payments not made through OCSPC shall not be considered as payment of support. Checks or money orders shall be made payable to 223OCSPC224. Cash payments to OCSPC may be made at the Cuyahoga County Treasurer, Cashier222s Department, Cuyahoga County Administrative Headquarters, 2079 East 9th Street 226 1st Floor, Cleveland, Ohio 44115. All payments shall include the following: Obligor222s name, Social Security Number, SETS case number and Domestic Relations Court case number. If there is to be a withholding/deduction order, the support obligor shall make payments directly to OCSPC until the income source/financial institution begins withholding/deducting in the appropriate amount. Method to Secure Support Payments (Check one of the following three boxes) The Court finds that the support obligor receives income from an income source or has nonexempt funds on deposit in an account at a financial institution. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that a withholding or deduction notice shall issue to: INCOME SOURCE/ FINANCIAL INSTITUTION: ADDRESS: If withholding from a financial account, the support obligor shall immediately notify the CJFS-OCSS of the number and description of the account from which support shall be deducted, and the name, branch, business address and routing number of the financial institution if not set forth above. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the support obligor immediately notify the CJFS-OCSS, in writing, of any change in employment (including self-employment), receipt of additional income/monies or termination of benefits. The support obligor shall include a description of the nature of the employment and the name, business address and telephone number of any employer. The support obligor shall immediately notify the CJFS-OCSS of any change in the status of an account from which support is being deducted or the opening of a new account with any financial institution. The Court finds that the support obligor has no attachable income source and has the ability to post a cash bond. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the support obligor post a cash bond in the amount of $ with the Clerk of the Common Pleas Court within 30 days. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the support obligor shall immediately notify the CJFS-OCSS, in writing, if the support obligor begins to receive income from a payor. The notice shall include a description of the nature of any new employment, and the name, business address and telephone number of any new employer. American LegalNet, Inc. www.FormsWorkFlow.com H953(Revised