PRINT FORM CLEAR FORM CODE ­ J180$ IN THE COURT OF COMMON PLEAS OF FRANKLIN COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH MAGISTRATE'S ORDER / ORDER AND NOTICES TO OBLIGOR AND OBLIGEE, PAYOR, AND INSURER CASE NO. JUDGE Full Names of Children Subject to Child Support Order: Name: Name: Residence Phone: Mailing Address (If Different): Name: Name: Name: Health Insurer: Address: DOB: DOB: DOB: DOB: DOB: PLAINTIFF / PETITIONER SSN: DOB: Driver's License Number: Residence Address: CHECK WHICH PARTY IS TO BE REIMBURSED FOR OUT-OF-POCKET MEDICAL, OPTICAL, HOSPITAL, DENTAL, OR PRESCRIPTION EXPENSES PAID FOR THE CHIILD AS PROVIDED IN PARAGRAPH 16 ON PAGE 3. Plaintiff Petitioner-Wife Defendant Petitioner-Husband Policy Number: DEFENDANT / PETITIONER DOB: SSN: Driver's License Number: Residence Address: Name: Address: Other Party (Specify Name and Address) Residence Phone: Mailing Address (If Different): Health Insurer: Address: PAYOR: Employer / Income Withholder / Financial Institution: Address: Policy Number: Employee Identification Number or Financial Institution Account Number The court has issued or modified a support order. Therefore, the following notices and orders shall issue. It is ORDERED, ADJUDGED, AND DECREED that the Health Plan Administrator do the following: 1. A health plan administrator that receives a copy of an order or notice described in sections 3119.30, 3119.36 or 3119.421 of the Revised Code shall complete and comply with the notice in accordance with its instructions, federal regulations and any rules adopted by the department of job and family services under Revised Code 3119.51. A health plan administrator that provides health insurance coverage for the children who are the subject of a child support order in accordance with the child support order or a notice sent by an employer pursuant to R.C.3119.36 shall reimburse the individual who is designated to receive reimbursement in the child support order as stated on page one of this order, for covered out-of-pocket medical, optical, hospital, dental, or prescription expenses incurred on behalf of the children. It is further ORDERED, ADJUDGED AND DECREED that: (Check applicable box in paragraphs 2 through 5) [ ] 2. The obligor under the c hild support order shall obtain private health insurance coverage for the children if coverage is available through a group polic y, contract, or plan FORM 1 - 7/ 08 PAGE 1 of 3 ALSO COMPLETE ODHS FORMS 4047 & 4048 J ­ 205I (Rev. 10/08) American LegalNet, Inc. www.FormsWorkFlow.com CODE ­ J180$ available to the obligor at a more reasonable cost than coverage is available to the obligee. [ ] 3. The obligee under the c hild support order shall obtain private health insurance coverage for the children if coverage is available through a group polic y, contract, or plan available to the obligee and is available at a more reasonable cost than coverage is available to the obligor. [ ] 4. If health insurance coverage for the children is not available at a reasonable cost to the obligor or the obligee, the obligor and the obligee shall immediately inform the child support enforcement agency that private health insurance coverage for the children has become available to either the obligor or obligee. The child support enforcement agency shall determine if private health insurance coverage is available at a reasonable cost and if coverage is available, shall apply R.C.3119.30(B)(2) or (3), as applicable. [ ] 5. Both the obligor and the obligee under the c hild support order shall obtain private health insurance coverage for the children if coverage is available for the children at a reasonable cost to both the obligor and the obligee and dual coverage would provide for coordination of medical benefits without unnecessary duplication of coverage. It is further ORDERED, ADJUDGED AND DECREED that: 6. All parties to this order shall notify the FCCSEA in writing of your current mailing address, current residence address, current residence telephone number, current driver's license number, and of any changes to that information. The parties affected by the support order shall inform the FCCSEA of any change of name or change of conditions that may affect the administration of the order. Until further notice, all parties shall notify the FCCSEA of any change in information immediately after the change occurs. A WILLFUL FAILURE TO SUPPLY THE FRANKLIN COUNTY CHILD SUPPORT ENFORCEMENT AGENCY WITH ALL CHANGES IS CONTEMPT OF COURT. 7. The obligor shall immediately notify the FCCSEA in writing of any change in your income source and of the availability of any other sources of income that can be the subject of withholding or deduc tion, the nature of any new employment or income source and the name, bus iness address and telephone number of the new employ er or income source. Additionally, if support is being deducted from the obligor's financial account, the obligor shall immediately notify the FCCSEA in writing of any change in the status of the account from which the support is being deducted or the opening of a new account with any financial institution, the nature of the new account opened at a financ ial institution and the name and bus iness address of that financial institution, or the commencement of employment, including self-employment, or of the availability of any other sources of income that can be the subject of withholding or deduction. If support is being deducted from a financial account, upon commencement of employment the obligor may request that the court or the FCCSEA cancel its deduction notice and issue a withholding notice to collect support amounts. 8. An obligor who fails to comply with a child support order issued in accordance with R.C. 3119.30, is liable to the obligee for any medical expenses incurred as a result of the failure to comply with the order. An obligee who fails to comply with a child support order issued in accordance with R.C.3119.30, is liable to the obligor for any medical expenses incurred as a result of the failure to comply with the order. 9. Whoever violates an order issued under R.C.3119.30 may be punished as for CONTEMPT under R.C. Chapter 2705. If a pers on is found in contempt under R.C. Chapter 2705 for failing to comply with a court child support order issued in accordance with R.C. 3119.30 and the person previously has been found in contempt under that chapter, the Court shall consider the failure to comply with the order as a