6-15-17 EXHIBIT 1 Page 1 of 2 COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS LAKE COUNTY, OHIO : CASE NO. PLAINTIFF : JUDGE vs. : : HEALTH CARE DETERMINATIONS DEFENDANT [Cash Medical Support: O.R.C. 2473119.30(C)] [Private Health Insurance: O.R.C. 2473119.302] Cash Medical Support Worksheet) is less than [OR] greater than or equal to 150% of the federal poverty guideline for an individual ($12,060 x 150% = $18,090.00 for the year 2017). obligation is $ per month ($per month per child), plus 2% processing charge. (Line 31, Child Support Computation Worksheet-Sole Residential Parent or Shared Parenting Order or Line 29, Child Support Computation Worksheet-Split Parental Rights and Responsibilities) 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. Private Health Insurance Neither party has Private Health Insurance available to cover the minor children. One or both of the parties has/have Private Health Insurance available to cover the minor children. a) Accessibility The private health insurance available to the Plaintiff and/or the Defendant: Plaintiff Defendant provides primary care services within thirty miles from the residence of the child(ren) subject to the child suppo rt order. geographic area customarily travel farther distances than thirty miles for primary care services. American LegalNet, Inc. www.FormsWorkFlow.com 6-15-17 EXHIBIT 1 Page 2 of 2 is accessible because primary care services are only available to the child(ren) by public transportation. b) Reasonableness The cost of private health insurance to the Plaintiff is $ (cost of adding the child(ren) to existing coverage or difference between self-only and family coverage), which: exceeds the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). does not exceed the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). The cost of private health insurance to the Defendant is $ (cost of adding the child(ren) to existing coverage or difference between self-only and family coverage), which: exceeds the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). does not exceed the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). (Check applicable box(es) if cost of Private Health Insurance EXCEEDS the Health Insurance Maximum) Both parties agree that: Plaintiff shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. Defendant shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. both Plaintiff and Defendant shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. Plaintiff has requested to obtain or maintain the private health insurance that exceeds the health insurance maximum for that parent. Defendant has requested to obtain or maintain the private health insurance that exceeds the health insurance maximum for that parent. The following private health insurance coverage is available to the Plaintiff and/or Defendant through a group policy, contract, or plan at a reasonable cost: Insurer: Available to: Plaintiff Defendant Plaintiff Defendant Plaintiff and Defendant should be designated as the Health Insurance Obligor(s), until further order of Court. American LegalNet, Inc. www.FormsWorkFlow.com