affidavit of income expenses and financial disclosure

8/10/2019 Affidavit of Income Expenses and Financial Disclosure

1/13

. '

COURT OF COl\Ii\ION PLEAS

DIVISION OF DOMI':STIC RELATIONS

HAMn,TON COUNTY, OHIO

MELISSA HENDON DETERS

Plaintiff

Date:

Case i'/o.

File No.

CSEA No.

Judge

DR1302

2

34

Address: 11976 Stonernark Lane

Loveland, 011

45140

VS.

AFFlDAVIT OF Ii'/COME, EXPENSES

A, D FINA.l'\'CIAL IJISCLOSURE

JOSEPH THEODORE DETERS

Defendant

Address: 15 W Fourth Street #503

Cincinnati, OH 45202

STATE OF OH IO , SS :

N ow comes M elis 'a H end on D eters, affi an t h er ei n, and having been duly cautio ned and swor n, st ate s that she has

been adv ise d th at this affida vit may be used for any or all of the fo llow ing purposes: (I) to m ake complete d isclo sure of

a ff ia nt 's i ncome, liabilities an d expenses; (2) t o a ss ist in dete rmining ord ers o f ch ild sup port o r spo usa l su pp ort w hen

a pp li ca ble o r any ch ange s th eret o; and

(3)

to provi de for the issuance of the ap pro priate de duction ord er for s up po rt.

M inor and/or Depende n t Children of thi s Marriage:

~P- .a- -tn.:..:: c: :.:k ,-,,J,,-. D e te ,rs ,-, ag e 9 i s r e sid ing w ith . . : . . . 1 _

... ,tv -'ra - 'ry~E I~yse '_ 'D =et e_ '_ 'rs '__ age 20 i s r e sid ing w ith ..:...1 _

= .:Jo~nC a .th .. a~n_'_' . . . . .r '_'.~et e_'_ 'rs '__ age

23

is re siding w ith _

,Jo ,:; c p-,-,-h-,,S,,-. D :..>e -'te -'.f--s age

::.24-'--

i s r e sid ing w ith _

GROSS YEARLY INCOME

SECTrON r

Husband

$87.828.00

(1)1

Yes_ No Em ployed?

l

Ycs_ No

(2)

Wife

... ....... Estimate Base yearly wages Estimare $50.000.00

........ .... ....... ...... Y e arly A ve ra ge s, O v ert im e, C o mm is sio n

&

Bonu s Incom e

$ O - ' . - . O O ~ _

0.00

H am ilto n C ou nty Prosecu to r

Employe r

Public Librnry of Cincinnati and

Ham il to n C ou nt y F ou nd at io n

80 0 V ine S treet

3Q

E . 9 th S treet S uite

Pa yr oll A dd ress

City, Stat e, Z ip

S chedu led Pay checks Per Y ear

Unemploy ment Benefits

Workers' Compensation

S o ci al S ec ur ity or O ther D is ab il it y B e ne fi ts

L is t S o ur ce in S ection D -2

Spousa l Support Received

Interest/D ividend Incom e

L is t S o ur ce in Sectio n

0-2

Public A ssistance or

I nc om e S u pp le m ent Security

O th er In co me Rece ived

list

Source in S ection IIl-B

TOTAL YEARLY INCOME

Cinc innati. Oh io 45202

.... ... ........ ...... ... . 1 2 .

$0.00

$0.00

$0.00

$0.00

0 00

S O . O O

$202,800 $0.00

$290.628.00

$50.000.00

D R 7.3 (Revised 07 /01 /2001)


2/13

Husband (I) Wife (2)

ANNUAL INCOME, OVERTIME AND BONUSES EARI~ED

(Past Three Years)

Overtime.

and/or

Bonuses

2 0 1 0

year

3 . .. '- $ 0 - ' . ' 0 0 - - - -_ $ 0 - ' - . 0 - '0 - -_

2 0

I

I year

2 .

$ 0 . 0 0 -- - - _ _ $ 0 '- . 0 ' 0 - -_

2 0 1 2 year I . . . = $ 0 = . 0 ' 0 ' -- - _ _ $ 0 .0 0

Base Income Base Income

Overtime,

and/or

Bonuses

$ 0 . 0 0

0 1 0

year

3 = $ O ~ .O = O _

2 0 I I

year

2

= S O - , . , ,o O ~ _ _

2 0 1 2

year I

$ 0 = . 0 '0 ' - - - _ _

$ 0 . 0 0

S O .O O per year

S O per year

MOST RECENT

YEAR

D.JUST;\,I ENTS

.............. Court Ordered Support Paid for other child(ren) .

........ Court ordered Spousal Support Paid to a Fonner Spouse .

. .. .. Number of Other Dependant Children living with the Party .

(Excluding Unadopted Step Children)

.... .. .. . Child Support Received for Other Dependent Children

$

--'p e::..r..r.V 'C . , 3 = 8 = 3 ~ . 8 ; . . : . . 1 _

DR

7 . 3

(Revised

0 7 1 0 1 1 2 0 0 1 )

PI .2


3/13

C. MONTHLY INSTALLMENT PAYMENTS

(Do not list expenses previously listed in Section B)

TO WHOM PAID PURPOSE BALANCE DUE

MONTHLY

PAYMENT

$500.00

ifth Third Master Card

Credit Card

11,403.79

Fifth Third Master Card Credit Card

7,855.36

$500.00

Visa

Credit Card

14,195.19

$500.00

AAA- Bank of America

Credit Card

9.500.00

S500.00

Bank of America Visa Credit Card 34,000.00 $1,000.00

Macy's American Express

Credit Card

$125.00

GE

Credit Union

Buick Loan 41 \3 .0 0

VWCredit

Passat Loan

$155.37

MONTHLY TOTAL

$3,763.37

$18,486.75

GRANO TOTAL MONTHLY EXPENSES (Sum A, B, C, plus D (optional) .

SECTION III FINANCIAL DISCLOSURE

A. list all funds on deposit in any and all accounts in any bank, savings loan, credit union, regulated investment

company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of

deposit ( CD), investment, savings, individual retirement ( IRA), stock option, etc. Attach additional pages

if

needed.

Name and Address of

Financial Institution

Fifth Third Bank

Account No. Name(s) on Accounts Balance Dat e of

this Affidavit

xxx586 Joseph Deters

S ;

Filth Third Bank

x x x 5

Joseph and Melissa

$

Deters

Huntington Bank

x x x 4

Joseph and M elissa

Deters

Huntington Bank

xxx06n

Melissa Deters

Fifth Third Bank

Melissa Deters $

Huntington Bank xxx760 Melissa Deters

B.

Other income sources listed in Section

I (i.c.,

retirement/pension benefits, disability income, interests or dividend

income, rentals, annuities, etc., not listed in Section III-A). Attach additional pages if needed. Need not complete prc-

decree.

Name & Address of Source

Identifying Description

(Account No., Claim No., etc.)

Income

or Benefits

Per Month

$ per _

O

DR 7.3 (Revised 0710112001)


4/13

;;

SECTION IV

OTHER ASSETS AND LUMP SUM TNCOME

1. Describe assets of more than $1,000 in value not otherwise listed in this affidavit (equity in real estate, stocks,

b on ds , o th er in ve stm e nt s, e tc .) , A tt ac h a d di ti on a l p a ge s

if

needed .

NONE

Value

_

2 . L ist any lum p sum incom e (bonus, g ifts , inhe ritance, e tc .) in excess

of

$5 00 , expected to be received w ith in the next

si x months, not otherwise listed in this affidavit. Attach additional pages if needed.

Source NONE

Value '$ _

A ddrcss _

Affiant states that the information contained herein is complete and accurate to the best of his/her information,

kn ow led ge or b elie f un der p en alty of

law.

Atfi

n t:

tto rn ey f or P la in tif f

______ ,2o~3

i A M g d H , M O ~ K O W n t .

A t t 5 I 'i l 8 i

d U J 1 1 I

aTARY

PUBliC. 'TATS 0 1' o J ff O

My Cornrnlsalon has no explrctUOlT

dote. 64 CUoo

147.03

OACt

D R 7 J ( Re vis ed 0 7/0 1 (2 0 01 )


5/13

I

D. OPTIONAL

(Additional Monthly Expenses)

Complete if an award of spousal support is at issue or in the event that you are seeking a significant deviation from the

child support schedule.

I .

Special and Unusual Needs of the Children, Specify: ,,

$ 0 . 0 0 _

2 .

Extraordinary Visitation-Related Travel Expenses

, $ 0 ' . 0 ' - 0 _

3. Extraordinary Obligations to other children, minor and handicapped, not step-children

. $ 0 . 0 0 ' -- _

4 . Mandatory Deduction from Wages (Not taxes, Social Security . O ~ . O O ' -- _

5 .

Hair Care, Dry Cleaning

.$ 2 :: . . . 4 . - 2 - - ' . 5 ' - - ' : 0 ~ _

6. Newspapers, Periodicals, and Books

$ 0 . 0 0 ' - _

7 .

Child Care (not

e m p l o y m e n t

related) , ..

' $ - 0 ' - . 0 .. . , 0 ' - - _

8 . Children'S School Lunch Program . $ . . : . . . 1 0 . 0 0 - _

9. Children's Allowances, Activities . , , $ - ' - - 7 0 - - ' 0 ' - . 0 0 - - _

1 0 .

Tuition (lor Minor Children or Sell)

' S 1 . L . . 4 '6 6 ' . : < , 0 ' 0 _

I I .

Entertainment

. $ ' - 4 - ' - ' 5 : < . 0 ' - ' - . 0 ' - ' 0 ~ _

1 2 . Contributions $ . . . , 1 0 .. . ,0 ' - . 0 0 ' -- _

1 3.

Additional Taxes Paid (not from wages $ 0 ' . : . = , 0 0 _

14. Memberships (Associations, Clubs)

. $ - :< . 7 8 ~ . - - 0 0 - - _

1 5 . Travel, Vacations

. $ = 2 = 0 - ' 0 ' - ' - . 0 0 - - _

16. Water Softener $ 0 . 0 0 ' - - _

1 7 .

Housing Repairs

$ . . . . , 1 0 . . , 0 '. 0 0 - - _

1 8 . Housekeeping

S e r v i c e s

'$ . : . . ; 1 0 0 '. 0 0 ' - - _

1 9. L aw n Service .$ ' - ' - ' I R . : . . , : 4 . 0 '0 ' - - _

2 0 . O t h e r ( S p e c i f y ) S ch o o l s u p p l i e s % - , $ - ' - ' 1 5 . 0 = - 0 - - _

Gift, .$ 2 ' 5 ' 0 . 0 - -- 0 _

Sorority '- $ 4 . - ' ' ' ' ' 6 '' ' '' . 0 ' ' ' ' '0 ' ' - - _

Pets

$ 2 5 . 0 0

Mary Elyse Deter Rent $ 6 8 5 . 0 0

Cable for Boys $ - ' - - 8 . . , 0 . 0 ' 0 ' - - _

TOTAL OTHER EXPENSES

(D)

$ 5 . 2 0 1 . 5 0

D R 7.3 (R ev ise d 0 7 / 0 1 1 2 0 0 I)

1 \ . 5


6/13

I

~.,

COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

MELISSA HENDON DETERS

Date: _

Plaintiff

Cas e No.

D R 1 3

a

2

2 3 4

vs.

File No. _

JOSEPH THlWDORE DETERS

Defendant

CSEA No. _

Judge _

AFFIDAVIT

fN COMPLIANCE

WITH

Q 2723 OF THE mllo REVISED CODE

Melissa Hendon Deters discloses the following information under oath and represents that it is true to the best

of Wife knowledge and belief based upon what is reasonably ascertainable:

I.[

1 [

am requesting the court to not disclose my address or that of the child named below. Iam claiming t i H 1 I

my address is co nf ident ial pursuant [QOhio Revised Code 3127 .23(D) and should be placed under seal in that the health,

safety, or liberty of myself and/or the child would be jeopardized by the disclosure of the identifying inform ation. I

understand that a hearing will be held to determine whether the information can be disclosed based on

my

claim.

2 .

The name(s) and the present addressees), or the whereabouts,

oft he

child involved lire:

01. Patrick J. Deters

DOB 5/8/04

Present address:

1 1 976

Stonemark

Lane Loveland. Ohio 45140

3. The child have lived at the following addresstes) during th e las t 5 years:

Prior Address( es)

8256

Cherry laurel Court Liberty Township. Ohio45044

4. The name(s) and present address/es) of all persons with whom the child have lived during the past 5 years are:

J

oseoh Deters

Names

Melissa Deters and Marv Elyse Deters

Address] es)

11976 Stonemark Lane Loveland, Ohio 45140

1 5 W. FourthStreet #503, Cincinnati, Ohio 452Q2

37 37

Hazel Avenue Cins;innati, Ohio

4 5 2 1 2

onathan T. Deters and Joseph S. Deters

~ c:;. 5. I have not participated as a party, a witness, or in any way in so m e court action in this or another state

~ ~ ~ cercemint:i custody, support, care of or visitation or parenting time with these same child.

1j3~ < 1 . lWve

part ic ipa ted , I

have listed below the court, the case number, and kind of case:

o ?

7 .

u

') ('oJ \

~u-\...'

N ~

0 .

Case Num~ Name of Court Kind orCase

0~ ~

U --

d. e x . ..:N o. :~~ _

~\.J'J ~

DR 2.1 (May 2006)


7/13


8/13

DIVISION OF DOMESTIC RELATIONS

COURT OF COlVUvlON PLEAS

HAMILTON COUNTY, OHIO 0 R 1 3 0 2 '2 3 4

I\lcll~'Il1 Hendon Deters

Plalntitf

Case No. _

File

No. _

CSE,'

1 '. ' 0 . _

.JlId~e _

Jo se ph T heedore D eters

Defendllnt

GHOUP IIE,\LTH INSlmANCE ,'FrIOA IT

. ~ * ..

* .

* ....

. ;fr **

PL\l1\TIFF

DEFE:DANT

_y


9/13

DR624

EFF.10/08

Hamilton COUNTY DOMESTIC RELATIONS COURT

CHILD SUPPORT COMPUTATION WORKSHEET

SOLE RESIDENTIAL PARENT OR SHARED PARENTING ORDER

Name of parties

Husband

and

Wife

Case No.

Order No.

Number of minor children

1

The following parent was designated as residential parent and legal custodian:

t 8 J

mother

father

shared

Column I

Column II Column III

Father

Mother

Combined

INCOME:

1. a.

Annual gross income from employment or, when determined

appropriate by the court or agency, average annual gross

income from employment over a reasonable period of years

(Exclude overtime, bonuses, sel f-employment income,

or commissions) .......................................

281,220

49.992

b. Amount of overt ime, bonuses, and commissions

(year 1 represent ing the most recent year)

Father Mother

Yr. 3

(Three years ago) . . . .

Yr. 2

(Two years ago) ......

Yr. 1 (Last calendar year) ...

AVERAGE .............

(Include in Col. I and/or Col. /I the average of the three years or

the year 1 amount, whichever is less, if there exists a reasonable

expectation that the lotal earnings from overtime and/or bonuses

during the current calendar year will meet or exceed the amount

that is the lower of the average of the three years or the year 1

amount. If. however, there exists a reasonable expectation that

the total earnings from overtime/bonuses during the current

calendar year will be less than the lower of the average of the 3

years or the year 1emount, include only the amount reasonably

expected to be earned this year.) ..........................

0

0

2.

For self-employment income:

a. Gross receipts from business ..............................

0

s

0

b. Ordinary and necessary busmess expenses ...................

0

0

c. 5.6% of adjusted gross income or the actual marginal difference

between the actual rate paid by the self-employed individual

and the F.I.C.A. rate ....................................

s

0

0

d. Adjusted gross income from self-employment

(Subtract the sum of 2b and 2c from 2a) ......................

0

0

3.

Annual income from interest and dividends

(whether or not taxable) .................... _ .............

0

0

4. Annual income from unemployment compensation ..............

$

0

s

0

O l62 4 E ffe ct ; , 1 0 1 (1 8

MoskowItz Moskcwtz, t LC Prep ared b y J ames H. MoskowItz. Eq. James Mosko wi tz (e) Fa mi ly L aw Software. Inc . v 15.03 11120t2QIJ ,:03pm HUSband' & Wile

Pogo 1


10/13

Case No.

Order No.

Column I

Father

Column II

Mother

Column III

Combined

5. Annual income from workers' compensation, disability insurance

benefits, or Social Security Disabil ity/Retirement benefits ._~ __

. . : . O

. . : . 0

6. Other annual income (identify) , . , $

. . . . : : . 0

__ ..:..:1

: . . : 0 : . . c , D : . . : D : . . : : . D

Mother:

Alimony from this relationship , 1 8 0 , 0 0 0

7. a. Total annual gross income (Add lines 18, 1b, 2d, and 3-6)

b. Health insurance maximum (Multiply line 78 by 5%), , , ,

2 8 1 , 2 2 0 $ _ - - -- = 2 .: : . . 2 9 : . , : , 9 :. . : 9 :. . . : : c 2

1 4 , 0 6 1 1 : . . . : 1 2 . : .5 : . : : . . : : .

ADJUSTMENTS TO INCOME:

B.

Adjustment for minor children bom to or adopted by either

parent and another parent who are living wi th this parent;

adjustment does not apply to stepchildren (number of

children limes federal income tax exempt ion less child

support received, not to exceed the federal tax exempt ion) ,$ . . . . : : . 0

. . : . 0

9.

Annual court-ordered support paid for other children , , , , , .. ,

,,$

: 0

: 0

10, Annual cour t-ordered spousal support paid to any spouse or

former spouse. , . , , , . .. , . , .... , , , , . , , , , . , . , .. , , . , , , ...

1 8 0 , 0 0 0 - - = . O

11.

Amount of local income taxes actually paid or estimated to

be paid , , , , , , , .. , , , . , . . ..

5 , 9 0 6

1 ' : : 0 : . . : 5 : . . : : . 0

12.

Mandatory work-related deductions such as union dues,

uniform fees, etc. (not including taxes, Social Secun ty, or

retirement) ..... , , . , . , ... , , , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : . 0 . . : : . 0

13.

Total gross income adjustments (Add lines 8 through 12) . . . . . . . ..

1 8 5 , 9 0 6 __ . . . : 1 c . .: , O : . : 5 ~ 0

14. a. Adjusted annual gross income

(Subtract l ine

13

from line 7a)

__

.. . : 9 : . : 5 c . . : , 3 : . : 1~4

b. Cash medical suppor t maxJmum (If the amount on line 7a, Col. I,

is

under 150 of the federal poverty level for an individual,

enter SO on l ine 14b, Col. I. If the amount on line 7a, Col. I,

is 150 or higher

of

the federal poverty level for an individual ,

multiply the amount on line 14a. Col. I, by 5% and enter this

amount on line 14b, Col.

I.

If the amount on line 7a, Col. II,

is under 150 of the federal poverty level for an individual,

enter S O on line 14b, Col. II. If the amount on line 7a, Col. If,

is 150 or higher of the federal pover ty level for an individual,

multiply the amount on /ine 14a, Col. II, by

5%

and enter this

amount on line 14b. Col. If.) , .. .~ __ 4 : : . , 7 : . . : 6 : . . : : 6

2 2 8 , 9 4 2

1 1 , 4 4 7

15.

Combined annual income that is basis for child support order

(Add line 14a, Col, I and CoI , / I ) , , , , , . . . . . . . . . . . . . . . , , ,

$__

3 _ 2 4 . . : . . , 2 _ 5 _ 6

0 .6 2 4 E ffe c Uv e 1 0 1 0 8

r . 10SkOWi t z

MO$ o.owi tz.I,. . I.C Prepared

by J am es H ,

Moskowitz.

Esq. J ame s

Moskowitz

(c ) Fam i l y

LU' t 'VSoftware.

In c . v

15.03 1 1 12OO01 J

1 : pm HUSba n d

Wile

Pao2


11/13

. '

Case No.

Order No.

Column I

Father

Column II

Mother

Column III

Combined

16. Percentage of parent's income to total income

a. Father

(Divide line 14a. Col.

I.

byline

15.

Col. I II). . . . .. . . .. .

29.39 %

b.

Mother (Divide line 14a. Col.

1/.

by line

15,

Col. 1 1 / ) . . .. . . .. . . . . . . . .. . . . .. . .. . .

70.61 %

1 7 .

a.

Basic combined child support obligation (Refer to schedule, first

column. locate the amount nearest to the amount on line 15.

Col.

I I I .

then refer to column for number of children

in

this

family. If the income of the parents is more than one sum but

less than another. you may cetcutete the difference.) _~_1_5,-,,-,2_1_8

b .

Income above top guideline bracket.

1 7

4.256

C. Percenttobeusooonincomeover 150.000......... 10.1453

%

d.

Support on Income over 150.000 (b c 1 _ 7 . : . . , 6 _ 7 _ 9

o. Total child support obligat ion (a + d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

$~ __

3_2..:..,8_9_7

18. Annual support obligation per parent

a. Father (Multiply line 17c, Col. 1 1 by line 16a) 9,668

b. Mother (Mult iply l ine 17c, Col. I I I , by line 16b) $~ __ 2 - , 3 - , - . 2 _ 2 _ 9

19. Annual child care expenses for children who are the subject

of this order that are work-, employment training-. or

education-related. as approved by the court or agency _~~ __

O

0

(Deduct tax credit from annual cost, whether o r not claimed)

a. Less: Federal chi ld care tax credit .......................... 0 0_

b. Less: OH child care tax credit ........................... 0 0

c. Net child care costs 0 0

20. a. Marginal, out-of-pocket costs. necessary to provide for health

insurance for the children who are the subject of this order

(Contributing cost of private family health insuranco,

minus the contributing cost of private single neet tn

insurance. divided by /he total number of dependents

covered by the plan. including the children subject of the

support order, t imes the number

01

children subject of the

support order)

0

- ' - 0

b. Cash medical support obl igation (Enter the amount on line 14b or

the amount of annual health care expenditures est imated by

United States Department of Agricul ture and described in section

3119.30 of the Revised Code. whichever amount

is

lower). . . . . . ..

1 . 2 8 9 1 . : . . : . . 2 . . . ; . . 8 . . ; . . 9

21. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED:

Father (only

if

obligor or shared parenting) Mother (only i f obligor or shared parenting)

a. Additions; line 16a times sum of amounts shown on b. Additions: line l6b times sum of amounts shown on

line 19c. Col. I/and line 20a, Col. /I tine 19c. Col. I and line 208, Col. I

$ 0 _

C. Subtractions; line lob times sum of amounts shown on d, Subtractions: line 16a times sum of amounts shown on

line 19c, Col. I and line 20a, Col. I line 19c. Col. /I and line 20a, Col. /I

0

_

v,

D L6 24 E H~ tt l , \ 0 1 08

MoskOWitz

&

Mos;owito:. tlC Prep.:lIrod byJ


12/13

.

Case No.

Order No.

Column I

Father

Column 1 1

Mother

22. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED:

a. Father: line 18a plus or minus the dif ference between line

21a minus line 21,c 9,668

b.

Mother.

line 18b plus or minus the difference between line

21b minus line 21d 23.229

23.

ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS PROVIDED:

a. (Line 22a or 22b, whichever line corresponds to the

parent who is the obligor) __ - - = 9 J . ; , 6 : . ; 6 : . : : . 8

b. Any non-means-tested benefits. including Social Security

and Veterans benefits. paid

1 0

and received by

a

child

or a

person on behalf of the child due to death. disability. or

ret irement of the parent . ; ; . . 0

c. Actual annual obligation (Subtract line 23b from line 238). . . . . . . .. $__ - - = 9 ~ , 6 : . : 6 : . : : . 8

_---

_---

_---

24. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED:

Father (only i f obligor or shared parenting) Mother (only if obligor or shared parenting)

a. Additions:

line 16a times sum of amounts shown on b.

Additions:

line

lob

times

sum of amounts shown on

line 19c. Col. I f and line 20b. Col. If line 19c, Col.Ind line 20b, Co/. I

$ 379

_

c. Subtractions: line t6b times sum of amounts shown on d. Subtractions: fine 16a times sum of amounts shown on

line 19c, Col. J and line 20b, Col. I line 19c. Col. 1/and line 2Gb. Cof. /I

$ 910

. ~

25. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED:

a. Father: line 18a plus or minus the dif ference between line

24a

minus l ine 24c

9,137

b. Mother.

fine 18b plus or minus the difference between line

24b and fine 24d . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ..

23,229

26.

ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS NOT PROVIDED:

a.

(Line 25a or 25b, whichever line corresponds to the parent

who is the obligor) ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9,137 _

b.

Any non-means-tested benefits, including Social Security

and Veterans benefits, paid to and received by a child or a

person on behalf of the child due to death, disability, or

retirement of the parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 $. _

c. Actual annual obligation (Subtract line 26b from line 26a) . . . . . . . .. 9,137 _

27. a. Deviat ion from sole residential parent suppor t amount shown on line 23c if amount would be unjust or inappropr iate:

(see section 3119.;?3 of the Revised Code.) (Specific facts and monetary value must be stated. )

i. Sole custody deviation when heal th insurance is provided 40 000 _

ii. Sole custody deviation when health insurance NOT is provided 0 _

D l6 2 4 E ff ec ti ve 1 0 1 M

Moskowltz MoskOWitz. l Prepared by James H. MoskOWItz..ESQ.James Moskowitz c) Family Law

Software,

Inc. v 15.03 11120120131:03pm Husband & .

Wife


13/13

Case No.

Order No.

b. Deviation from shared parenting order. (see sections 3119.23 and 3119.24 of the Revised Code.) (Specific facts including

amount of time children spend with each parent, ability of each parent

/0

maintain adequate housing for children, and

each parents expenses for children must be stated 10 juslify deviation.)

i. Shared custody deviation when health insurance is provided:

ii. Shared custody deviation when health insurance is NOT provided:

WHEN HEALTH

INSURANCE IS

PROVIDED

WHEN HEALTH

INSURANCE IS

NOT PROVIDED

OBLIGOR

Father/Mother

28. FINAL CHILD SUPPORT FIGURE:

(This amount reflects final annual child support obligation;

in Col. I, enter line 23c plus or minus any amounts indicated

in line 27a or 27b; in Col. II. enter l ine 26c plus or minus any,

amounts indicated in line 2 7a or 27b) . . . . . . . . . . . . . . . . . . . . . .. $

49,668 $

---- --

, 1 3 7

FATHER

29. FOR DECREE: Child support per month (Divide obligors In 28., by 12)

... before any processing charge . . . . . . . . . . . . . . . . . . . . . . . . .. 4 ,1 39

-.: 7... .::6'-'.1

. . . 2 %

processing charge of ; ..

8 _ 3

1 .. :. . 5

... including processing charge 4 .2 2 2 .. : . . 7 . . . : . 7 . c : , 6

30. FINAL CASH MEDICAL SUPPORT FIGURE:

(This amount reflects the final. annual cash medical support

to be paid by the obligor when neither parent provides health

insurance coverage for the child; enter obligors cash

medical support amount from fine 20b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 1 ,289

31. FOR DECREE: Cash medical support per month (Divide In 30. by 12)

... before any processing charge 1 07

.. . 2 % processing charge of

2

... including processing charge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 109

Prepared by:

Counsel:

Pro se:

(For motherlfather)

CSEA:

Other. _

Worksheet Has Been Reviewed and Agreed To:

Mother

Date

Father

Date

0 .6 24

E H e c U . . . ,

10 1 08

Moskowitz

Mo,kow;'z, LLC PrOP od by James H. Moskowllz, Esq. James Moskowitz (e) Family Law Softwa

affidavit of income expenses and financial disclosure

Documents