Dissolution with Children 31 IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION MEDINA COUNTY, OHIO ) CASE NO. NAME ) ) ADDRESS ) JUDGE MARY R. KOVACK ) CITY, STATE, ZIP ) ) DATE OF BIRTH ) P etitioner - 1 ) ) and ) ) ) JUDGMENT ENTRY NAME ) DECREE OF DISSOLUTION ) ADDRESS ) ) CITY, STATE, ZIP ) ) DATE OF BIRTH ) Petitioner - 2 ) This matter came on for hearing on the day of , 20, before the Honorable Mary R. Kovack, Judge of the Medina County Common Pleas Court, Domestic Relations Division, upon the Petition of the parties for a dissolution of marriage and the Separation agreement as attached. Both Petitioners were present in Court, and were representing themselves. Based upon the testimony and evidence presented, the Court finds as follows: More than thirty (30) days have elapsed after the filing of the Petition of Dissolution of Marriage and that one or both of the Petitioners were residents of the State of Ohio for at least six (6) months and County of Medina for at least ninety (90) days immediately preceding the filing of the Petition herein, and that service thereof was waived by both Petitioners. The parties were married in the State of , on the day of , , and child(ren) was/were born as issue of said marriage, to wit: Name(s): Birthdate(s): American LegalNet, Inc. www.FormsWorkFlow.com Dissolution with Children 32 The Petitioners have acknowledged that they voluntarily entered into the Separation Agreement and Parenting Plan attached to the original Petition of Dissolution, which the Court finds to be fair and equitable, and each Petitioner is satisfied with the terms and conditions contained in said Separation Agreement and Parenting Plan and each Petitioner has made full disclosure of his or her assets, and each desire that the Court ratify, approve and incorporate said Separation Agreement and Parenting Plan into this final Decree. That irreconcilable differences have arisen between the parties and that each Petitioner desires to have the marriage contract terminated and dissolved. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the marriage contract existing between the Petitioners be and the same is hereby dissolved, terminated and set aside. IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Separation Agreement and Parenting Plan attached to the original Petition filed herein, a copy of which is attached as Exhibit A, is approved and incorporated into this Decree as if fully rewritten at length. THE ALLOCATION OF FINANCIAL RESPONSIBLITIES FOR THE MINOR CHILD(REN) PRIVATE HEALTH INSURANCE FOR THE MINOR CHILD(REN) IT IS SO ORDERED: BOTH PARENTS SHALL PROVIDE HEALTH INSURANCE. Both the Mother and Father shall obtain private health insurance coverage for the child(ren) if it is available at a reasonable cost and dual coverage would provide for coordination of medical benefits without unnecessary duplication of coverage. [R.C. 3119.30(B)(1)] THE OBLIGOR SHALL PROVIDE HEALTH INSURANCE. The person who PAYS child support (the OBLIGOR) shall obtain private health insurance coverage for the child(ren) if it is available through any group policy, contract, or plan available to the OBLIGOR at a more reasonable cost than coverage is available to the person who receives child support (the OBLIGEE). [R.C. 3119.30(B)(3)] THE OBLIGEE SHALL PROVIDE HEALTH INSURANCE. The person who RECEIVES child support (the OBLIGEE) shall obtain private health insurance coverage for the child(ren) if it is available through any group policy, contract, or plan available to the OBLIGEE at a more reasonable cost than coverage is available to the person who pays child support (the OBLIGOR). [R.C. 3119.30(B)(2)] NEITHER PARTY SHALL PROVIDE HEALTH INSURANCE. American LegalNet, Inc. www.FormsWorkFlow.com Dissolution with Children 33 Choose ONE of the following: Neither party has private health insurance coverage for the child(ren) available at a gross income is not considered available at a reasonable cost. Both parties shall immediately inform the Child Support Enforcement Agency when or if private health insurance coverage for the child(ren) becomes available to either party. The Child Support Enforcement Agency shall determine if the private health insurance coverage is available at a reasonable cost and if coverage is reasonable, whether the OBLIGOR or OBLIGEE shall be ordered to provide such coverage. [R.C. 3119.30(B)(4)] One or both parties has private health insurance coverage available at a reasonable cost, but the Court finds that ordering one or both parties to obtain such coverage is not One or both parties has private health insurance coverage available at a reasonable cost, but it is not accessible because primary care is not available within thirty miles and it is not customary in this geographic region to travel more than thirty miles for primary care OR because the child(ren) rely on public transportation and primary care is not available in this area via public transportation. [R.C. 3119.302(A)(4)]. OBLIGOR OBLIGEE SHALL PROVIDE HEALTH INSURANCE THOUGH IT IS NOT AVAILABLE AT REASONABLE COST BECAUSE: (Choose ONE) The parties agree that health insurance coverage costing more than five percent 3119.302(A)(2)(a)] The party requests to be allowed to provide health insurance coverage for the minor child(ren) that costs more than five percent (5%) of his or her gross income. [R.C. 3119.302(A)(2)(b)] party to provide health insurance coverage for the children that costs more than five percent (5%) of his or her gross income an further finds that it is not an undue financial burden on either party. [R.C. 3119.302(A)(2)(c)] MEDICAL EXPENSES CHILDREN WHO ARE COVERED: Within thirty (30) days of this Order, the person(s) ordered to provide private health insurance coverage for the children shall designate the following children as covered dependents under any health insurance or health care policy, contract or plan. [R.C. 3119.32(C)]: Name(s): Address: DOB(s): American LegalNet, Inc. www.FormsWorkFlow.com Dissolution with Children 34 DUTY TO SUPPLY HEALTH INSURANCE INFORMATION: Within thirty (30) days of this Order, the party ordered to provide health insurance shall supply the other party with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment of other benefits under the health insurance coverage, and a copy of any necessary insurance cards. [R.C. 3119.32(A)] ALLOCATION OF UNREIMBURSED MEDICAL EXPENSES: The OBLIGOR (the person who pays child support) and the OBLIGEE (the person who receives child support) shall pay the reasonable and ordinary uninsured and unreimbursed medical, dental, optical and prescription drug expenses for the minor children as are defined pursuant to R.C. 3119.01 with the OBLIGOR paying % and the OBLIGEE paying %. [R.C. 3119.32(D)] RELEASE OF HEALTH INSURANCE INFORMATION: The employer of the person required to obtain private health insurance coverage shall release to the other parent, any person subject to an order issued pursuant to R.C. 3109.19 or the Child Support Enforcement Agency, on written request, any necessary information on the private health insurance coverage, including the name and address of the health insurance plan administrator and any policy, contract, or plan number, and shall otherwise comply with this section and any order or notice issued pursuant to this section. [R.C. 3119.32(E)] HEALTH INSURANCE REIMBURSEMENTS: The health insurer shall reimburse whichever party incurs the expense for out-of-pocket medical, psychological, dental, optical or prescription expenses paid for the above referenced children [R.C. 3119.32(B)] HEALTH INSURANCE PAYMENTS TO PROVIDERS: The health insurer(s) referenced in this Order may continue making payments 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. [R.C. 3119.32(B)] HEALTH INSURANCE CHANGES: If the person required to obtain private health care insurance coverage for the children subject to this child support orde