COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO _________________________________________ Plaintiff _________________________________________ Date of Birth _________________________________________ Address _________________________________________ City, State, Zip Code Yes No Marital Residence: vs ________________________________________ Defendant _________________________________________ Date of Birth _________________________________________ Address _________________________________________ City, State, Zip Code Marital Residence: Yes No : : : : : : : Filed by:__________________________ (Your Name) Case Number: ___________________________________ Judge: ___________________________________ MOTION FOR TEMPORARY SUPPORT WITH AFFIDAVIT AND NOTICE : : : WIFE HUSBAND Date of Marriage:____________________________ Date of Separation: __________________________ Plaintiff Defendant (print your name) ______________________________ files this Motion and Affidavit under Rule 75(N) of the Ohio Rules of Civil Procedure to request the following temporary support orders in the amounts stated: Check all that apply: Child support Spousal support (alimony) Payment of these debts and/or expenses: _________________________ $___________ _________________________ $___________ _________________________ $___________ _________________________ $___________ _________________________ $___________ Total debts and/or expenses TOTAL AMOUNT REQUESTED $ 0.00 $ 0.00 Per month Per month $ $ Per month Per month Plaintiff Defendant (print your name) _____________________________, having been duly sworn states that he/she has been advised that this affidavit will be used for the following purposes: (1) to disclose completely affiant's income and expenses; (2) to assist in determining orders of child support and spousal support, and payment of debts and expenses when applicable or any changes thereto; and (3) to provide for the issuance of an appropriate support withholding and deduction notice or other order. NOTICE TO OTHER PARTY Plaintiff Defendant is hereby notified of the filing of this Motion for Temporary Support with Affidavit and Notice. Plaintiff Defendant is hereby directed to complete a Counter Affidavit and, within 14 days after receiving this notice, file the Counter Affidavit with the Clerk of Courts, basement of the County Courthouse, 1 W. Lakeside Ave. Cleveland, Ohio 44113 Room 35. If he/she fails to do so, the Affidavit supporting this motion will be taken as true. A form Counter Affidavit is available at www.cuyahogacounty.us/domestic/ and in the Court's Information Center in Room 306 of Cuyahoga County Courthouse, 1 W. Lakeside Ave. Cleveland, Ohio 44113. Initial: ________ Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com A. I. Information Required for Support Calculation: Minor or Dependent Children of this Marriage (Include adopted children and any child of the parties who is over 18 and still attending high school or is mentally or physically disabled) Child's Name Date of Birth Age Residing with ARE THERE ANY OTHER SUPPORT ORDERS ESTABLISHED FOR THESE CHILDREN? YES NO IF YES, ATTACH COPY OF ORDER AND PROVIDE THE FOLLOWING INFORMATION: DATE OF ORDER:_________ AMOUNT: $____________ CASE NUMBER: ________________ SETS NUMBER: ___________________ COURT (or agency) NAME: ______________________________ B. Other Minor Children Living in My Household. Child's Name Child's Relationship to You Date of Birth Age $ $ $ Court Ordered Support Received C. Other Minor Children of Mine, NOT Living in My Household. Child's Name Residing with Date of Birth Age $ $ $ Court Ordered Support Paid II. Child Support Guideline Adjustment: Husband/Father (all figures per year) Wife/Mother (all figures per year) $ $ Total court ordered child support you pay for other children Total court ordered spousal support you pay to former spouse(s) Number of your other dependent children living with you from another marriage or relationship Court ordered child support you receive for the dependent child(ren) you indicated on line above Childcare expenses you pay for child(ren) of this marriage (employment or educational related) Local income taxes paid or rate of tax where you live or work Self-employment tax (5.6% of A.G.I.) Health insurance premium for children (family plan cost minus individual plan cost) A. $ $ $ $ $ $ $ % $ $ $ $ $ % III. Annual Income [as defined in Ohio Revised Code §3119.01(B)(5)]: Gross Annual Income from Employment (If not known, please estimate and write "EST" after each estimated figure.) Gross Annual Husband/Father Wife/Mother Employment Income $ Salary Wages $ Salary Wages Name(s) of Employer(s) Payroll Address(es) City, State, Zip Check the number of 12 24 26 52 12 24 26 52 paychecks per year Through date of: Through date of: Year-to-date Gross Income $ $ Prior Year's Tax Refund $ $ Benefits from Employment (Company Car, Club Memberships, Stock Options, etc.) 1. 2. 3. Total Annual Value of Benefits: $ $ $ $ 0.00 Initial: ________ $ $ $ $ 0.00 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com B. Annual Overtime, Commissions and Bonuses (If not known, please estimate and write "EST" after each estimated figure.) Husband/Father Base Income Overtime, Commissions & Bonuses Base Income Wife/Mother Overtime, Commissions & Bonuses LAST YEAR: 2 YEARS AGO: 3 YEARS AGO: $ $ $ Month Day Year $ $ $ $ $ $ $ $ $ $ $ $ $ THIS YEAR THROUGH C. Gross Annual Self-Employment Income (If not known, please estimate and write "EST" after each estimated figure.) Use gross annual figures for most recent full year. See Ohio Revised Code §3119.01(C)(13) Gross Annual Business Receipts Ordinary & Necessary Business Expenses Net Annual Business Income D. $ -$ = $ 0.00 Company Name Company Address Nature of Business: Other Annual Income: Other income includes commissions (other than from employment), royalties, tips, rents, dividends, severance pay, interest, trust income, annuities, social security benefits (including retirement, disability and survivor benefits that are not need based), workers' compensation, unemployment insurance, spousal support actually received, recurring capital gains, etc. Also include military pay (including base pay, BAQ, BAS, specialty pay, variable housing allowance, training pay, combat pay, hazardous duty pay, etc). Need Based Assistance includes benefits received from a government-administered means-tested program such as Ohio works first, food stamps, S