COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... DR-5 THE PEOPLE OF THE STATE OF NEW YORK IN THE COMMON PLEAS COURT OF SHELBY COUNTY, OHIO DOMESTIC RELATIONS DIVISION TO GREETINGS: Name:__________________________ * Address:________________________ excuses being laid aside, you and each of you attend before WE COMMAND YOU, that all business and ________________________________the * , the Honorable at Court located at County of SS#: in room DOB: , on the day of , 20 , o'clock in the noon, and at any recessed * at or adjourned date, to testify and give evidence as a witness in this action on the part of the PLAINTIFF/OBLIGOR(EE) * CASE NO. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to VS. * JUDGE __________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Name:__________________________ * Address:________________________ Witness, Honorable ________________________________ * Court in County, day of , 20 SS#: DOB: * DEFENDANT/OBLIGEE(OR) * * * * * * * * , one of the Justices of the ORDER HEALTH INSURANCE COVERAGE O.R.C. 3113.217 (Attorney must sign above and type name below) * Attorney(s) * for * * * * The following group health insurance and health care policies, contracts, and plans are available at reasonable cost to the Obligor or Obligee: (List name of insurer, and contract or policy number). Office and P.O. Address Name of Plan/Insurer Available to: Policy/Contract# _________________________ ___________________ Telephone No.: _______________________ _________________________ ___________________ E-Mail Address: Facsimile No.: _______________________ Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA ORDER ON OBLIGOR : (Alternative I) : [ ] The Court finds that the Obligor under the Child Support Order is _________________________ and that the Obligor should be ordered to : obtain health insurance coverage through ______________________ ( Name of Employer or other group plan) AND that health insurance Defendant(s) : . . . . . . . . .coverage .is . . . . . . . . . . . at. a . . . . . reasonable. cost.through a group health insurance or health care policy, . . . . . . . . not available . . more . . . . . . . . . . . . . . . contract, or plan available to the Obligee. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that no later than 30 days after the issuance of this Order, the Obligor obtain health insurance coverage for the following child(ren): (Name, DOB, SS#) ______________________________ and furnish the written proof to the Shelby County Child Support Enforcement Agency (CSEA) that the required health insurance coverage has been obtained. THE PEOPLE OF THE STATE OF NEW YORK TO IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligor supply the Obligee with information regarding the benefits, limitations, and exclusions of the health insurance coverage, copies of COMMAND forms necessary to receive reimbursement, payment, or other benefits under the health WEany insurance YOU, that all business and excuses being laid aside, you and each of you attend before insurance coverage, and a copy of any necessary insurance Court that the Obligor submit a copy of this , cards; the Honorable at the located at County of Order to the insurer at the time application is made to enroll the child(ren) and that the Obligor, no later that in room 30 days , on the issuance of this Order, furnish written proof to the CSEA that noon, and at any recessed day of , 20 , at o'clock in the after the the foregoing Orders have or adjourned date, to testify and give evidence as a witness in this action on the part of the been complied with. GREETINGS: ORDER ON OBLIGEE Your failure to comply with this subpoena is (Alternative II) punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. [ ] The Court finds that the Obligee under the Child Support Order is _________________________ and that the Obligee has health insurance coverage to him/her through ______________________ ( Name Witness, Honorable , one of the Justices of the of Employer or other group plan) AND it is available to the Obligee at a more reasonable cost than health Court in County, day of , 20 insurance coverage available to the Obligor. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Obligee obtain health (Attorney must sign above and type name below) insurance for the following child(ren): (Name, DOB, SS#) ______________________________. IT IS FURTHER ORDERED, ADJUDGEDAttorney(s) for that the Obligee within 30 days of AND DECREED the issuance of this Order, furnish written proof to the CSEA that the required coverage has been obtained AND submit a copy of this Order to the insurer at the time the Obligee makes application to enroll the child(ren). Office and P.O. Address ORDER ON BOTH OBLIGOR AND OBLIGEE DUAL COVERAGE (Alternative III) No.: Telephone Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. [ ] The Court finds that health insurance coverage:is available at a reasonable cost to the Obligor JUDICIAL SUBPOENA Plaintiff(s) through ________________ and the Obligee through _________________ and that dual coverage by -against: both parents would provide for coordination of medical benefits without unnecessary duplication of coverage. : IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that within 30 days of the : issuance of this Order, both Obligor and Obligee provide health insurance coverage for the following Defendant(s) : . . . . . . . . .child(ren):. (name, DOB,.SS#) _______________________________________________________. ........ ........... ........................ IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligee and Obligor within 30 days of the issuance of this Order, furnish written proof to the CSEA that the required coverage has THE PEOPLE OF THE STATE OF NEW YORK been obtained AND submit a copy of this Order to his and her insurer at the time he and she makes application to enroll the child(ren). TO ORDER WHEN INSURANCE IS NOT AVAILABLE (Alternative IV) GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before [ ] The Court finds that neither the Obligor norCourt has health insurance coverage Obligee , the Honorable at the located at County of for the minor child(ren) available at a reasonable cost through a group health insurance plan offered by his or in room her employer or any other of , on the day group health insurance plan available to him or her. noon, and at any recessed , 20 , at o'clock in the or adjourned date, to testify and give evidence as a witness in this action on the part of the IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that Obligor and Obligee shall share responsibility for the cost of the medical and health care needs of the child(ren) as outlined below. If, Your failure to comply Order, health insurance coverageas a contempt of court andbecomes available at to after issuance of this with this subpoena is punishable for the minor child(ren) will make you liable a the party on whose behalf through a group health insurance plan offered by the Obligor’s ordamages sustained asor reasonable cost this subpoena was issued for a maximum penalty of $50 and all Obligee’s employer a result of your failure to comply. through another group health insurance plan available to Obligor or Obligee to whom the coverage becomes available shall inform the Shelby County CSEA and this Court of that fact. Court in Witness, Honorable County, , one of the Justices of the day of , 20 (Applicable to all Orders) IT IS FURTHER ORDERED, ADJUDGED AND DECREED that both Obligor and Obligee, (Attorney must sign above and type name below) within 30 days of the issuance of this Order, designate the child(ren) who are the subject of the Child Support Order as covered dependents on any health insurance plan for which they contract. Attorney(s) for IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor/Obligee/both Obligor and Obligee be responsible for co-payments, deductibles, and uninsured cost for medical expenses incurred on behalf of the minor child(ren). Office and P.O. Address (1) in accordance with Local Rule 17 of the Rules of Court, Common Pleas Court, Shelby County, Ohio, Domestic Relations Division. A copy of Local Rule 17 is ATTACHED hereto and incorporated herein byNo.: Telephone reference as if fully rewritten herein; Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : OR (2) Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA -against: in amounts equal to the percentages indicated on Line 14 of the current Child Support Computation Worksheet; : OR : Defendant(s) : . . . . . . . . . . . . . . .(3) . . . . .in.accordance .with. the. following .formula: __________________________________ .. . ......... ... .. ........ .... Reimbursement for out-of-pocket medical, optical, hospital, dental, or prescription expenses paid for the for the following child(ren) _________________________ shall be THE PEOPLE OF THE STATE OF NEW YORK made to: TO GREETINGS: Name: ______________________________________________________________ Address:_____________________________________________________________ Telephone: ___________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before The insurer that provides the health insurance coverage for the child(ren) may continue making , the Honorable at the Court located at County of payments for medical, optical, hospital, dental, or prescription services directly to any health care provider in room in accordance with the applicable health ,insurance or healtho'clock in thecontract, or and at any recessed , on the day of 20 , at noon, plan. care policy, or adjourned date, to testify and give evidence as a witness in this action on the part of the NOTICE TO OBLIGOR, OBLIGEE, EMPLOYER, INSURANCE COMPANY O.R.C. 3113.217 (C), (E), (F), (G), (J) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this O.R.C. 3113.217 (E), this maximum binding of $50the Obligor and Obligee, their Pursuant to subpoena was issued for a Order is penalty upon and all damages sustained as a result of your failure to comply. employers, and any insurer that provides health insurance coverage for them or their child(ren). Court in Witness, Honorable , one of the Justices of the If the Obligor or Obligee fails to obtain health insurance coverage for the child(ren) or to comply County, day of , 20 with the requirements in this Order, the Court immediately shall issue an Order to the employer of the Obligor or Obligee, upon written notice from the CSEA, requiring the employer to take whatever action is necessary to make application to enroll the Obligor or Obligee in any available group health insurance or (Attorney must sign above and type name below) health care policy, contract, or plan with coverage for the child(ren) who are the subject of the Child Support Order, to submit a copy of the Court Order to the insurer at the time that the employer makes application to enroll the child(ren) and, if the Obligor”s and Obligee”s application is accepted, to deduct any Attorney(s) for additional amount from the Obligor’s or Obligee’s earnings necessary to pay any additional cost for that health insurance coverage. During the time that this Order is in effect, and after the employer has received a copy of this Order, Office and P.O. Address the employer of the Obligor or Obligee who is the subject of the Order shall comply with the Order and, upon request from the other party or agency, shall release to the other party and the CSEA all information about the Obligor’s or Obligee’s health insurance coverage thatNo.: Telephone is necessary to ensure compliance with O.R.C. 3113.217 or any Order issued under that Facsimile No.: section, including, but not limited to, the name and E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. address of the insurer and any policy, contract, or plan number. Any information provided by an employer : JUDICIAL SUBPOENA Plaintiff(s) pursuant to this division shall be used only for the purpose of the enforcement of an Order issued under -against: O.R.C. 3113.217. Any employer who receives a copy of an Order issued under O.R.C. 3113.217 shall notify the : CSEA of any change in or the termination of the Obligor’s or Obligee’s health insurance coverage that is maintained pursuant to an Order issued under this section. : Defendant(s) : . . . . . . . . . . . . . . . Any insurer which.provides health .insurance. coverage in accordance with an Order issued under ............... ............ ....... .. O.R.C. 3113.217 shall reimburse the parent who is designated to received reimbursement in this Order for covered out-of-pocket medical, optical, hospital, dental, or prescription expenses incurred on behalf of the child(ren) subject to the Order. THE PEOPLE OF THE STATE OF NEW YORK TO _______________________________________ Magistrate GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _______________________________________ , the Honorable at the Court located at County of Judge in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the pc: OBLIGOR: OBLIGEE: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. OBLIGOR EMPLOYER: Witness, Honorable Court in County, day of OBLIGEE EMPLOYER: , one of the Justices of the , 20 NAME AND ADDRESS (Attorney must sign above and type name below) OBLIGOR INSURER: Attorney(s) for OBLIGEE INSURER: NAME AND ADDRESS Office and P.O. Address Policy No. ____________________ **** Policy No.____________________ Telephone No.: Facsimile No.: DON’T FORGET TO ATTACH A COPY OF LOCAL RULE 17 TO THIS ORDER. E-Mail (IF THAT PROVISION IS MADE HEREIN) Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com