(Name)

(Address)

(City, State, Zip)

(Telephone Number)

(Date of Birth)

Plaintiff /Petitioner

VS

(Name)

(Address)

(City, State, Zip)

(Telephone Number)

(Date of Birth)

Defendant/Petitioner

IN THE COMMON PLEAS COURT OF __________ COUNTY, OHIO JUVENILE DIVISION

) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

Case Number -------

Judge:

Magistrate:

COMPLAINT TO ESTABLISH COURT CHILD SUPPORT ORDER AND/OR MEDICAL SUPPORT ORDERS

1. I, ________________ am the Plaintiff in- this case and statethat:

2. I am o Mother

following child(ren): o Father o non-parent, guardian or legal custodian of the

AFFIDAVIT 1

Plaintiff/Petitioner 1

v./and

Defendant/Petitioner 2

COURT OF COMMON PLEAS

______COUNTY, OHIO

Case No.

Judge

Magistrate

Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write "none" where appropriate. If you do not know exact fi ures for an item, ive our best estimate and ut "EST." If ou need more space, add additional a es.

AFFIDAVIT OF INCOME AND EXPENSES

Affidavit of --------------------

Date of marriage

SECTION I - INCOME

(Print Your Name)

Date of separation ----- -----

Employed

Employer

Payroll address

Payroll city, state, zip

Scheduled paychecks per year

_________ Your Name

□ Yes D No

_______ Spouse's Name

□ Yes D No

□ 12 024 □ 26 □ 52 □ 12 □ 24 □ 26 □ 52

A YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS

Base yearly income

Yearly overtime, commissions and/or bonuses

Supreme Court of Ohio

$

$

$

$

$

$

Uniform Domestic Relations Form - Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Amended: March 15, 2016

Your Name

3 years ago

2 years ago

Last year

3 years ago

2 years ago

Last year

Spouse's Name

20 $

20 $

20 $

20 $

20 $

20 $

Page 1 of 7

OATH

(Do not sign until notary is present.)

I, (print name) _________________ , swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.

Your Signature

Sworn before me and signed in my presence this __ day of

Supreme Court of Ohio Uniform Domestic Relations Form -Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Amended: March 15, 2016

Notary Public

My Commission Expires:

Page 7 of 7

AFFIDAVIT 4

Plaintiff/Petitioner 1

v./and

Defendant/Petitioner 2

COURT OF COMMON PLEAS

_________ COUNTY, OHIO

Case No.

Judge

Magistrate

Instructions: Check local court rules to determine when this form must be filed. h°his affidavit is used to disclose health insurance coverage that is available for children. It is also used to determine child support. It must be filed if there are minor children of the relationship. If more space is needed, add additional pages.

HEALTH INSURANCE AFFIDAVIT

Affidavit of --------------------

Are your child(ren) currently enrolled in a low-income government-assisted health care program (Healthy Start/Medicaid)?

Are you enrolled in an individual (non­group or COBRA) health insurance plan?

Are you enrolled in a health insurance plan through a group (employer or other organization)?

If you are not enrolled, do you have health insurance available through a group (employer or other organization)?

Does the available insurance cover primary care services within 30 miles of the child(ren)'s home?

Supreme Court of Ohio Uniform Domestic Relations Form - Affidavit 4 Health Insurance Affidavit Approved under Ohio Civil Rule 84 Amended: March 15, 2016

(Print Your Name)

_______ Your Name ______ Spouse's Name

□ Yes D No □ Yes D No

□ Yes D No □ Yes D No

DYesD No □ Yes □ No

DYesD No □ Yes D No

D Yes D No □ Yes D No

Page 1 of 2

APPLICANT NAME: _____________ __DATE MAILED OR DELIVERED TO APPLICANT: ______ _

APPLICATION NUMBER (CSEA USE ONLY): ADDRESS:

APPLICATION AND QUESTIONNAIRE FOR CHILD SUPPORT SERVICES

The Child Support program aims to provide services to help families by promoting family self-sufficiency and child well-being. Services are available to either parent when one parent is living outside the home. Services are also available to caretakers of children. Services are available automatically for families receiving assistance under the Ohio Works First (OWF) program.

The child support enforcement agency (CSEA) can assist you with the following services: 1. Establishment of Paternity - Legally Identifying a Child's Father

The CSEA can assist in establishing paternity (legal fatherhood) if there has not been a final and enforceable determination of paternity forthe child.

2. Establishment or Adjustment of Child Support and Medical Support Orders The CSEA can assist in obtaining an order for child support and medical support. A support order establishes how much a parent shouldpay for child support. It also allocates the costs of providing for the health care of the child between the parents. The CSEA can assist in modifying a support order (review and adjustment) every 36 months or sooner if there is a qualifying change in circumstances.

3. Enforcement of Support Orders The CSEA can assist in collecting and disbursing current and past due support, as well as enforcing medical support orders. The parentordered to pay support (obligor), will be required to pay child support by income withholding. The CSEA will issue income withholdingorders to collect support from the parent's wages and/or unearned income. Overdue support may also be collected from Federal or stateincome tax refunds and liens placed on property. In addition, when past-due support is owed, the following may occur:

• Unpaid child support may be reported automatically to credit reporting bureaus• Driver's, professional, occupational and recreational licenses may be suspended if the obligated parent is not paying the required

support• The U.S. State Department will deny a passport to a parent who owes more than $2,S00 in back child support• Funds may be seized from financial institutions• Court actions, such as contempt, and possibly criminal actions may be taken against chronic delinquent parents

4. Location of ParentsThe CSEA can use available information to locate parents and their income and assets. The applicant can request "Location Only Services,"if the sole need is to find the whereabouts of the non-residential parent.

Child Support Services Requested: DAIi child support services available D Location of non-residential parent only Dother (please explain below):

Confidentiality of Case Material

PLEASE READ BEFORE SIGNING

RIGHTS AND RESPONSIBILITIES

You have the right to see the parts of your file at the CSEA about you and the actions taken for you by the agency. You cannot see some parts of your file that are protected by confidentiality laws, such as information obtained from the IRS. Information about you in the CSEA file is confidential. However certain portions of your file become public record when a court is notified about your case.

Hearing Rights If you disagree with an action, lack of action or delay by the CSEA, you may request a state hearing.

OWF Participants •� a condition of eligibility to receive Ohio Works First (OWF) benefits, you give up the right to keep child and spousal support up to the amount of assistance you received. You must

)perate in establishing paternity for each child born, if you were not married to the father. You must assist the CSEA in getting support payments and any other payments. If you fail.J cooperate without good cause (determined by the CSEA), you may be ineligible to receive OWF benefits.While a family is receiving OWF, support collections are used to repay benefits. When a family leaves OWF, current support and family arrears are released to the family. Paymentsfrom the IRS are applied to repay OWF benefits before being applied to support payable to the household.

Page 1 of 7

IN THE COURT OF COMMON PLEAS

JUVENILE Division

COUNTY, OHIO -------------

IN THE MATTER OF:

A Minor

Name

Street Address

City, State and Zip Code

Plaintiff/Petitioner

vs.land

Name

Street Address

City, State and Zip Code

Defendant/Petitioner

Case No.

Judge

Magistrate

Instructions: This form is used when you want to request documents to be served on the other party. You must indicate the requested method of service b markin the appro riate box.

REQUEST FOR SERVICE

TO THE CLERK OF COURT:

Please serve the following documents on the following parties as I have indicated below:

D Defendant/Petitioner at the address shown above.

D Certified Mail, Return Receipt Requested

D Issuance to Sheriff of _______ County, Ohio for D Personal or D Residence service

D Other (specify) Supreme Court of Ohio Uniform Domestic Relations Form - 28 Uniform Juvenile Form - 1 O REQUEST FOR SERVICE Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013 Page 1 of 2