COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO ____________________________________ PETITIONER-01 : CASE NO. DR ________________________ : and JUDGE ______________________________ : ____________________________________ PETITIONER-02 : JUDGMENT ENTRY OF DISSOLUTION (WITH CHILDREN) This cause came on for hearing on the _____ day of ______________, 20__ and was duly heard before: the Honorable ______________________________, Judge of the Domestic Relations Division of the Court of Common Pleas Magistrate ______________________________ to whom this cause 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. 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 there is/are _____ minor child(ren) of the marriage, to wit: Full name of each child(ren) _________________________________________________ _________________________________________________ _________________________________________________ Date of Birth ___________________ ___________________ ___________________ The Court further finds 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 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 hereby ordered into execution. SPOUSAL SUPPORT IT IS FURTHER 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 subject to the terms set forth in the Separation Agreement. H954/DR0908126-27 Dissolution with children 1 American LegalNet, Inc. www.FormsWorkFlow.com ALLOCATION OF PARENTAL RIGHTS AND RESPONSIBILITIES FOR THE CARE OF THE CHILD(REN) (Check applicable parenting arrangement and cross out alternative language) The Court finds that the parents’ Petition includes a request and a plan for shared parenting which plan the Court determines to be 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 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. -ORIT IS THEREFORE 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 attached hereto in accordance with the Standard Parenting Time Guidelines attached as Exhibit ____ and incorporated by reference. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the residential parent(s) shall 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. CHILD SUPPORT For purposes of this order Petitioner-01 Petitioner-02 is the Child Support Obligor and Petitioner-01 Petitioner-02 is the Child Support Obligee. This order for child support and cash medical support is effective ________________. The worksheet used to compute child support and cash medical support under Ohio Revised Code §3119.022 or §3119.023 is attached as Exhibit ____. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that when private health insurance IS being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) to the Child Support Obligee, and/or her assignee(s), plus 2% processing charge. (Line 29, Child Support Computation Worksheet-Sole Residential Parent or Shared Parenting Order or Line 27, Child Support Computation Worksheet-Split Parental Rights and Responsibilities) IT IS FURTHER ORDERED, ADJUDGED AND DECREED that when private health insurance IS NOT being provided by a party in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay child support for the minor child(ren) in the sum of $_____________ per month ($_____________ per month per child) to the Child Support Obligee, and/or her assignee(s), plus 2% processing charge. (Line 29, Child Support Computation Worksheet-Sole Residential Parent or Shared Parenting Order or Line 27, Child Support Computation Worksheet-Split Parental Rights and Responsibilities) (Check if applicable) The above child support deviates from the amount of child support that would otherwise result from the use of the Basic Child Support Schedule and the applicable worksheet, through the line establishing the actual annual obligation because, pursuant to Ohio Revised Code §3119.22 the amount H954/DR0908126-27 Dissolution with children 2 American LegalNet, Inc. www.FormsWorkFlow.com would be unjust and inappropriate and would not be in the best interest of the minor child(ren) for the following reason(s): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ CASH MEDICAL SUPPORT (Check applicable box) The Court finds that the Child Support Obligor’s total annual gross income (Line 7a, Child Support is less than 150% of the federal poverty guideline for an individual. Pursuant to Ohio Revised Code §3119.30(C) the cash medical support obligation is zero. Computation Worksheet) -ORThe Court finds that the Child Support Obligor’s total annual gross income (Line 7a, Child Support is 150% or more of the federal poverty guideline for an individual. Pursuant to Ohio Revised Code §3119.30(C) the cash medical support obligation is 5% of the Child Support Obligor’s adjusted gross income (line 14a) or the amount of cash medical support to be paid according to the Ohio Department of Job and Family Services USDA Cash Medical Support Schedule created pursuant to Ohio Revised Code §3119.302(B), whichever is the lower amount. Computation Worksheet) IT IS FURTHER ORDERED, ADJUDGED AND DECREED that insurance IS NOT being provided by a party in accordance with this order for above, the Child Support Obligor shall pay cash medical support in the sum of month ($_____________ per month per child), plus 2% processing charge. when private health the child(ren) named $_____________ per (Line 31, Child Support Computation Worksheet-Sole Residential Parent or Shared Parenting Order or Line 29, Child Support Computation WorksheetSplit Parental Rights and Responsibilities) If private health insurance coverage is being provided and becomes unavailable or is terminated, the Child Support Obligor SHALL BEGIN paying cash medical support commencing the first day of the month immediately following the month in which private health insurance coverage became unavailable or is terminated, and SHALL CEASE paying cash medical support on the last day of the month immediately preceding the month in which private health insurance coverage begins or resumes. Cash medical support shall be paid in addition to child support. (Check if applicable) The Court finds that the parties have an administrative support order, case number P_________________, (SETS #_________________) issued by the _______________County Child Support Enforcement Agency (COPY ATTACHED HERETO AS EXHIBIT ____) that requires ____________________ to pay child support in the amount of $_____________ per month when health insurance IS being provided by a party, and $_____________ per month plus cash medical support in the amount of $_____________when health insurance IS NOT being provided by a party, plus 2% processing charge, for the support of the above–named child(ren). The Court finds it appropriate to adopt this order for the purpose of preserving and determining arrearage accrued under the administrative order. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the administrative order is hereby adopted and any arrears and overpayments accrued under the administrative order are hereby preserved. The _________________ County CSEA shall terminate any support withholding or deduction notice issued in case number P-_________________. All support paid hereafter shall be under Cuyahoga County Domestic Relations case number DR_______________. The Child Support Obligor shall be given credit for any payments received under the administrative order. The Court further finds that as of ____________________ the arrearage is $_____________. H954/DR0908126-27 Dissolution with children 3 American LegalNet, Inc. www.FormsWorkFlow.com This sum includes all accrued child support, cash medical support, spousal support, processing charges, and arrearage accrued under the above-referenced administrative order, if any. This sum supercedes all prior determinations of arrearage. The Support Obligor has been credited with all support payments made through the CSEA, payments made directly to and acknowledged by the Child Support Obligee, credit acknowledged by the Child Support Obligee for support provided directly to the child, and credit for support waived by the Child Support Obligee, as of the computation date. The arrearage also includes the Child Support Obligor’s share of health care expenses not covered by private health insurance or cash medical support. (Appropriate box must be checked) IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Child Support Obligor shall pay an additional $_____________ per month toward the existing arrearage. -ORIT IS THEREFORE ORDERED, ADJUDGED AND DECREED that judgment in the amount of $________________ as and for support arrears is hereby entered in favor of ___________________ and against ____________________, and upon which execution may issue. The duty of support shall continue until further order of Court or until the above-named 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, or as otherwise provided in Ohio Revised Code §3119.86. Total monthly order is $_____________ when health insurance is provided. This includes: $__________.___ current child support (including 2% processing charge) $__________.___ current spousal support (including 2% processing charge) $__________.___ arrearage payment (including 2% processing charge). Total monthly order is $_____________when health insurance is not provided. This includes: $__________.___ current child support (including 2% processing charge) $__________.___ current spousal support (including 2% processing charge) $__________.___ current cash medical support (including 2% processing charge) $__________.___ arrearage payment (including 2% processing charge). 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 “OCSPC”. Cash payments to OCSPC may be made at the Cuyahoga County Treasurer’s Office, County Administration st Building, 1 Floor – Cashier, 1219 Ontario Street, Cleveland, Ohio 44113. All payments shall include the following: Obligor’s name, Social Security Number, SETS case number, and Domestic Relations Court case number. 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 sections 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. To secure the support obligations, the Court finds that: (Choose appropriate option for securing payments) The Child Support Obligor receives income from an income source. A withholding notice shall H954/DR0908126-27 Dissolution with children 4 American LegalNet, Inc. www.FormsWorkFlow.com issue in the amount of $_____________ per month. INCOME SOURCE ADDRESS ____________________________________________________ ____________________________________________________ ____________________________________________________ The income source shall be notified not to withhold a total amount, including all fees, in excess of the amount allowed under Section 303(b) of the “Consumer Credit Protection Act,” 15 U.S.C. 1673(B). Until the income source begins withholding in the appropriate amount, the Child Support Obligor shall make payments directly to OCSPC. The Child Support Obligor has nonexempt funds on deposit in an account at a financial institution. A deduction notice shall issue upon the account in the amount of $_____________ per month. FINANCIAL INSTITUTION ADDRESS ____________________________________________________ ____________________________________________________ ____________________________________________________ The Obligor shall immediately notify the CSEA of the number of the account from which support shall be deducted, and the name, branch, location and routing number of the financial institution if not set forth above. The Child Support Obligor has no attachable income source and has the ability to post a cash bond. An order to post bond in the amount of $_____________ shall issue. The Child Support Obligor has no attachable income and has no assets to post a bond. An order to seek work and report income shall issue. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligor immediately notify the CSEA, in writing, of any change in employment (including self-employment), receipt of additional income/monies or termination of benefits. The Obligor shall include a description of the nature of the employment and the name, business address and telephone number of any employer. The 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 a new account with any financial institution. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that pursuant to Revised Code §3119.82 the following person(s) shall claim the child who is/are the subject of this order as (a) dependent(s) for federal income tax purposes: Mother Father Both Mother and Father according to the following terms: ___________________________ ___________________________________________________________________________ ___________________________________________________________________________ IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the parties shall take whatever action is necessary pursuant to section 152 of the “Internal Revenue Code of 1986,” 100 Stat. 2085, 26 U.S.C. 1, as amended, to enable the parent who has been awarded the right to claim the exemption(s) to claim the child as (a) dependent(s) for federal income tax purposes in accordance with this order. Failure of a party to comply with the order may be considered contempt of Court. MEDICAL SUPPORT OF CHILDREN Pursuant to Ohio Revised Code §3119.30(A) both parents are liable for the health care of the H954/DR0908126-27 Dissolution with children 5 American LegalNet, Inc. www.FormsWorkFlow.com child(ren) who is/are not covered by private health insurance or cash medical support as calculated in accordance with §3119.022 or §3119.023, as applicable. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the child support OBLIGOR pay __________% and the child support OBLIGEE pay __________% of the 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. Private Health Insurance Findings A list of any private health insurance policies, contracts or plans available to the parties including a description of any private health insurance in which the Child Support Obligor, the Child Support Obligee, and the children are enrolled (Private Health Insurance Questionnaire) is attached hereto. (One of the following boxes MUST be checked) The Court finds that: neither parent has private health insurance available to cover the child(ren). the mother and/or father have the following private health insurance available for the child(ren) through a group policy, contract, or plan: Insurer: _______________________________________________ _______________________________________________ Available to: Mother Father (Accessibility) The Court further finds that the private health insurance available to the Mother and/or the Father: Mother Father (Check all applicable boxes) provides primary care services within thirty miles from the residence of the child(ren) subject to the child support order. -ORis accessible because residents in part or all of the child(ren)’s immediate geographic area customarily travel farther distances than thirty miles for primary care services. is accessible because primary care services are only available to the child(ren) by public transportation. (Reasonableness of Cost) The Court further finds that the contributing cost (cost of adding the child(ren) to existing coverage or of the private health insurance available to the Mother and/or the Father: difference between self-only and family coverage) Mother Fathe r (At least one box MUST be checked if private health insurance is available) does not exceed that party’s Health Insurance Maximum (line 7b of Child Support Computation Worksheet). exceeds that party’s Health Insurance Maximum (line 7b of Child Support H954/DR0908126-27 Dissolution with children 6 American LegalNet, Inc. www.FormsWorkFlow.com Computation Worksheet). The Court further finds that: (Check appropriate box(es) ONLY if applicable) both parents agree that Mother Father both parents shall obtain or maintain private health insurance that exceeds the Health Insurance Maximum for that parent. Mother Father 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 Mother Father to obtain or maintain private health insurance the contributing cost of which exceeds that party’s health insurance maximum because: ______________________________________________________________________________ ______________________________________________________________________________ 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 maximums because: ______________________________________________________________________________ ______________________________________________________________________________ ALTERNATIVE I IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Child Support Obligor and the Child Support Obligee shall immediately inform the CSEA if private health insurance coverage for the child(ren) becomes available to either the Obligor or the Obligee. The CSEA shall determine if the private health insurance is available at a reasonable cost and if coverage is reasonable, order the Obligor or the Obligee to obtain private health insurance. -ORALTERNATIVE II IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the following person(s) is/are hereby designated as the Health Insurance Obligor(s), until further order of Court: Mother Father Mother and Father The Health Insurance Obligor(s) shall provide private health insurance through: MOTHER: Name of employer/group/individual Address of employer/group/individual Customer service telephone number Group number Identification/Subscriber number _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ FATHER: Name of employer/group/individual _______________________________________ Name of health plan Name of insurance company Claims address of insurance company H954/DR0908126-27 Dissolution with children 7 American LegalNet, Inc. www.FormsWorkFlow.com Address of employer/group/individual Name of health plan Name of insurance company Claims address of insurance company Customer service telephone number Group number Identification/Subscriber number _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ and shall designate the following child(ren) as covered dependents under the private health insurance policy, contract or plan: Full name of each child subject to the Medical Support Order _________________________________________________ _________________________________________________ _________________________________________________ Date of Birth ___________________ ___________________ ___________________ IT IS FURTHER ORDERED, ADJUDGED AND DECREED that pursuant to Ohio Revised Code §3119.30 the parent(s) ordered to provide private health insurance for the child(ren) shall, not later than thirty (30) days after the issuance of the order, supply the other parent with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under the health insurance coverage and a copy of any necessary insurance cards. The following individual shall be reimbursed for covered out-of-pocket medical, optical, hospital, dental, or prescription expenses paid for the above-named child(ren): Name of party Address Telephone number _________________________________________ _________________________________________ _________________________________________ _________________________________________ The health plan administrator(s) of the health insurer(s) that provide(s) the private 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 private health insurance policy, contract, or plan. The employer(s) of the person(s) required to obtain private health insurance coverage is/are required to release to the other parent, any person subject to an order issued under §3109.19 of the Revised Code, or the CSEA, on written request, any necessary information on the private health insurance coverage, including the name and address of the health plan administrator and any policy, contract or plan number, and to otherwise comply with Ohio Revised Code §3119.32 and any order or notice issued under this section. If the person(s) required to obtain private health insurance coverage for the child(ren) subject to this child support order obtain(s) new employment, the agency shall comply with the requirements of section 3119.34 of the Revised Code, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child in private health insurance coverage provided by the new employer. Any employer who receives a copy of an order issued under Ohio Revised Code §3119.30, H954/DR0908126-27 Dissolution with children 8 American LegalNet, Inc. www.FormsWorkFlow.com §3119.33 or §3119.34 shall notify the CSEA of any change in or the termination of the Child Support Obligor’s or the Child Support Obligee’s private health insurance coverage that is maintained pursuant to the order. Upon receipt of notice by the CSEA that private health insurance coverage is not available at a reasonable cost, cash medical support shall be paid in the amount as determined by the child support computation worksheets in §3119.022 or §3119.023 of the Revised Code, as applicable. The CSEA may change the financial obligations of the parties to pay child support in accordance with the terms of the court order and cash medical support without a hearing or additional notice to the parties. APPLICABLE TO ALL ORDERS IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Child Support Obligor and the Child Support Obligee shall comply with the request of the CSEA in advance of an administrative review of a support order to provide the following: copy of federal income tax return from the previous year, copy of all pay stubs within the preceding six (6) months, copy of all other records evidencing the receipt of any other salary, wages or compensation within the preceding six (6) months, and, if the Obligor is a member of the uniformed services and on active military duty, a copy of the Obligor’s Internal Revenue Service Form W-2, “Wage and Tax Statement,” and a copy of a statement detailing the Obligor’s earnings and leave with the uniformed services. The Child Support Obligor and the Child Support Obligee shall also provide a list of available group health insurance and health care policies, contracts and plans, and their costs, the current health insurance or health care policy, contract, or plan under which the Obligee and/or Obligor is/are enrolled, and their costs, including any Tricare program offered by the United States Department of Defense available to the Obligee, and any other information necessary to properly review the child support order. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the residential parent and legal custodian of the child immediately shall notify, and the obligor under a child support order may notify, the CSEA of any reason for which the child support order should terminate, including but not limited to the child(ren)’s death, marriage, emancipation (age 18 or high school completion/termination), enlistment in the Armed Services, deportation, or change of legal custody. A willful failure to notify the CSEA is contempt of court. The following information is provided for the use of the CSEA in accordance with §3121.24 and §3121.30 of the Ohio Revised Code: OBLIGEE: NAME MAILING ADDRESS RESIDENCE ADDRESS RESIDENCE PHONE NO. SOCIAL SECURITY NO. DATE OF BIRTH DRIVER’S LICENSE NO. OBLIGOR: NAME MAILING ADDRESS RESIDENCE ADDRESS H954/DR0908126-27 Dissolution with children ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ 9 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENCE PHONE NO. SOCIAL SECURITY NO. DATE OF BIRTH DRIVER’S LICENSE NO. ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ The parties affected by the support order shall inform the CSEA of any change of name or other change of conditions that may affect the administration of the order. Willful failure to inform the CSEA of the above information and any changes is contempt of court. 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 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 ISSUED BY A COURT AND YOU WILLFULLY FAIL TO GIVE THE REQUIRED NOTICES, 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 GIVE THE REQUIRED NOTICES, 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 necessary to implement the orders herein, and was not submitted at the time of this final hearing pursuant to Local Rule 28(E)(l) of the Court of Common Pleas, Division of Domestic Relations, Cuyahoga County, Ohio, shall be prepared by the party noted in that Rule or ___________________________, no later than ________________ days from this date. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Court retains jurisdiction with respect to the Qualified Domestic Relations Order or Division of Property Order to the extent required to maintain its qualified status and the original intent of the parties. The Court also retains jurisdiction to enter further orders as are necessary to enforce the assignment of benefits to the nonparticipant as set forth herein, including the re-characterization thereof as a division of benefits under another plan, as applicable, or to make an award of spousal support, if applicable, in the event that the participant fails to comply with the provisions of this order. IT IS FURTHER ORDERED, ADJUDGED AND DECREED the participant shall not take actions, affirmative or otherwise, that can circumvent the terms and provisions of the Qualified Domestic Relations Order or Division of Property Order, or that may diminish or extinguish the rights and entitlements of the non-participant. H954/DR0908126-27 Dissolution with children 10 American LegalNet, Inc. www.FormsWorkFlow.com IT IS FURTHER ORDERED, ADJUDGED AND DECREED that _____________________ (DOB: _______________) be and is hereby restored to her former name of ______________________. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the costs of this proceeding shall be paid by ______________________________________. IT IS SO ORDERED. ___________________________________________ MAGISTRATE ________________________________________ JUDGE Approved by: _______________________________________ PETITIONER-01 _________________________________________ PETITIONER-02 _______________________________________ ATTORNEY FOR PETITIONER-01 _________________________________________ ATTORNEY FOR PETITIONER-02 H954/DR0908126-27 Dissolution with children 11 American LegalNet, Inc. www.FormsWorkFlow.com