COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIO Enter: Plaintiff/Petitioner ( ) Obligor ( ) Obligee Date: Case No. -vsFile No. CSEA No. Defendant/Petitioner ( ) Obligor ( ) Obligee Judge [ ] UNEMPLOYMENT / NOTICE ORDER O. R. C. § 3121.03 ******************* WHEREAS, Obligor has been ordered by this court to pay support and; WHEREAS, Obligor has no employment income, Workers' Compensation, Unemployment Compensation, or other income, financial institution accounts or other assets from which support payments can be paid or secured or from which a bond can be posted. NOW, THEREFORE, IT IS ORDERED that Obligor shall, unless medically unable, seek employment and IMMEDIATELY notify the Child Support Enforcement Agency, in writing, upon obtaining employment, income, or ownership of any asset with a value of five hundred dollars or more, and/or upon the occurrence of any of the events listed on the reverse side of his/her copy of this order. In the absence of present employment, income, or financial institution accounts or other assets from which support payments can be paid or secured or from which a bond can be posted, Obligor shall immediately register with the OhioMeansJobs program. IT IS FURTHER ORDERED that a Deduction/Bond Order shall be imposed at such time as Obligor becomes employed or acquires other income assets. IT IS FURTHER ORDERED that each party to this action shall notify the Child Support Enforcement Agency, in writing, of their respective current mailing address AND current residence address, and each party shall notify the Agency IMMEDIATELY IN WRITING of any change in either of their addresses. CSEA, 222 E. Central Pkwy, Cincinnati, OH 45202-1225. IT IF FURTHER ORDERED that the residential parent (Obligee) shall notify the CSEA IMMEDIATELY IN WRITING, of any reason for which the support order shall terminate, including but not limited to death, marriage, emancipation, incarceration, enlistment in the Armed Services, deportation, or change of legal or physical custody of the child. TAKE NOTICE THAT A WILLFUL FAILURE TO NOTIFY THE CSEA AS REQUIRED ABOVE IS CONTEMPT OF COURT AND WILL BE PUNISHED BY LAW. This order will remain in full force and effect until further order of this court. INSTRUCTIONS TO THE CLERK: YOU ARE DIRECTED TO MAIL ORDINARY MAIL, WITH PROOF OF MAILING, A COPY OF THIS ORDER TO ANYONE BELOW WHO HAS NOT OTHERWISE ACKNOWLEDGED RECEIPT OF IT BY SIGNATURE. [ ] Obligor [ ] Obligee Name Address City (You need 5 copies) Name Address State Copies to: [ ] Clerk Zip [ ] Court City [ ] CSEA Page 1 [ ] Obligee State [ ] Obligor American LegalNet, Inc. www.FormsWorkFlow.com Zip DR 7.10 (Revised 09/22/2015) OBLIGOR NOTIFICATION THE OBLIGOR IS ORDERED to notify the Child Support Enforcement Agency of any change in employment (including self-employment). The Obligor (employee) shall include in the notification a description of the nature of employment and the name, business address and telephone number of any new employer. DIRECT PAYMENTS ARE A GIFT. All payments are to the CHILD SUPPORT ENFORCEMENT AGENCY. The Obligor is ordered to IMMEDIATELY notify the Child Support Enforcement Agency of any of the events specified in the list of instructions below. The Obligor's failure to comply with the foregoing order of notification may result in a finding of contempt. Attorney fees and Court cost may then be assessed against the Obligor held in contempt. INSTRUCTIONS Please check the appropriate boxes below and fill in needed information when any of these events occur and mail this document to: HAMILTON COUNTY DEPARTMENT OF HUMAN SERVICES CHILD SUPPORT ENFORCEMENT AGENCY 222 E. CENTRAL PKWY CINCINNATI, OHIO 45202-1225 A. EMPLOYMENT FINANCIAL CHANGES: I have terminated effective I will be laid off effective I will be employed at (name Employer and Payroll Address) My new rate of pay will be $ gross per per year; I will receive my first pay on I will become self-employed effective This business will operate under the name Said business shall have its business account at (Financial Institution) (address) . , for weeks indefinitely. . ; I am scheduled to receive . . 12 24 26 52 paychecks . I am drawing sick leave from (institution) (Address) (City, State, Zip Code) My Workers' Compensation (Claim No. ) will commence terminate on . Benefit amount is $ gross per My Unemployment (Claim No. ) will commence terminate on . Benefit amount is $ gross per I am retiring effective and will receive retirement benefits paid (Source) (Address) I have opened a Financial Institution account in the name of : , Account No. at , Address (City, State, Zip Code) in the name of disability benefits in the amount of $ per . starting on . . . 52 times per year. 12 24 26 . I have acquired or expect to receive one or more of the following: Lump sum payment in excess of $500 as a result of: from (address) Real property located at . Other property with a value in excess of $1000 described as follows: . Other income or assets not otherwise included on this form such as lottery proceeds, inheritance, insurance settlements, tax refunds, etc., describe as follows: . Other changes in employment or financial condition . B: CHILD SUPPORT/SPOUSAL SUPPORT (ALIMONY) OBLIGATION CHANGES: Effective , child support for born , should terminate because this child graduated form high school no longer resides with Obligee married enlisted in Armed Forces was adopted by Decree of Adoption. (Attach documentation. Example: copy of high school diploma, certificate of marriage, military ID card, etc.) Child support should increase decrease pursuant to the specific terms of the Final Decree filed in this action. Effective , Spousal support (alimony) should terminate remarriage full-time employment ordered time has expired any other reason please describe . (Attach documentation) Spousal support (alimony) should increase decrease pursuant to the specific terms of the Final Decree filed in this action. Date: Case No. A/DR File No. E CSEA Account # Obligor's Signature Address City, St, Zip Check if New Address Telephone Number : ( Page 2 ) American LegalNet, Inc. www.FormsWorkFlow.com DR 7.10 (Revised 09/22/2015) OBLIGEE NOTIFICATION IT IS FURTHER ORDERED that where there are minor children the RESIDENTIAL PARENT shall notify the Child Support Enforcement Agency IMMEDIATELY IN WRITING of any reason for which the support order shall terminate, including but not limited to death, marriage, emancipation, i