COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO

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Plaintiff	:	Case No.
:
Street Address	:
:	Judge
City, State and Zip Code	:
:
vs.	:	Magistrate
:
:
Defendant	:
:
Street Address	:
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City, State and Zip Code	:

FINAL JUDGMENT FOR DIVORCE WITH CHILDREN - PRIVATE HEALTH INSURANCE AVAILABLE
This matter came on for final hearing on	before Judge Magistrate
upon the Plaintiff’s Complaint for Divorce with Children filed on
and/or Defendant’s Counterclaim filed on
and upon the following:

FINDINGS
Upon a review of the record, testimony, and evidence presented, the Court makes the following findings:
A.	Check all that apply:
The Defendant was properly served with summons, copy of the Complaint, and notice of the hearing.
The Defendant’s waiver of service of summons and Complaint have been filed in this case.
The Defendant filed an Answer.
The Defendant failed to file an Answer or plead, despite being properly served with summons,
copy of the Complaint, and notice of the hearing.
The Plaintiff replied to the Defendant’s Counterclaim.
The Plaintiff failed to reply to the Defendant’s Counterclaim.
B.	Present at the hearing were the: Plaintiff, Defendant,
appearing as counsel for the Plaintiff.
appearing as counsel for the Defendant.
C.	The Plaintiff and/or Defendant was/were a resident(s) of the State of Ohio for at least six
months immediately before the Complaint and/or Counterclaim was/were filed.
D.	At the time the Complaint and/or Counterclaim was/were filed:
The Plaintiff was a resident of this county for at least 90 days.
The Defendant was a resident of this county.
Other grounds for venue were:
E.	The Plaintiff and Defendant were married to one another on	(date of marriage)
in	(city or county, and state). The termination of
marriage is the date of final hearing or as specified:
F.	Check all that apply regarding child(ren):
There is/are no child(ren) expected from this marriage or relationship.
There is/are child(ren) expected from this marriage or relationship and the approximate due date
is:
There is/are no child(ren) from this marriage or relationship.
The parties are parents of	(number) child(ren) from the marriage or relationship. Of
the child(ren),	(number) is/are emancipated adult(s) and not under any disability.
The following	(number) child(ren) is/are minor child(ren) and/or mentally or physically
disabled and incapable of supporting or maintaining themselves (name and date of birth of each child):
Name of Child	Date of Birth
Plaintiff is not the parent of the following child(ren) who was/were born during the marriage (name
and date of birth of each child):
Defendant is not the parent of the following child(ren) who was/were born during the marriage (name
and date of birth of each child):
G.	The following child(ren) from the marriage or relationship are subject to a custody or parenting
order in a different Court proceeding (name of each child and the Court that has issued the custody
or parenting order):
H.	Select one:
Neither the Plaintiff nor Defendant is in the military service of the United States.
The Plaintiff and/or Defendant is in the military service of the United States and
the service did not impact the ability to defend this action.
I.	The Plaintiff and/or Defendant through testimony have indicated full and complete
disclosure to the other of all marital property, separate property, and any other assets, debts,
income, or expenses.
The Defendant has not filed a response or made an appearance.
The Plaintiff has not filed a response or made an appearance.
J.	The parties that appeared have no knowledge of any other property and debts of any kind
in which either party has an interest.
K.	The parties that appeared have had the opportunity to value and verify all marital property,
separate property, and other debts.
L.	This Court has jurisdiction and proper venue to determine all of the issues raised by the
pleadings and motions.
M.	Select one:
A Magistrate’s Decision was filed on:
No objections were filed. The Court approves the terms contained in the Decision and finds the
terms are fair and equitable.
All objections were ruled upon by a separate entry.
The parties have presented the Court with a written Separation Agreement or have read
into the record a settlement of all issues, which the Court finds to be a fair and equitable division
of property and debts and an appropriate resolution of all issues, knowingly and voluntarily
entered into by the parties.
The Court has made a fair and equitable division of property and debts and an appropriate
resolution of all issues of the parties after review and consideration of all evidence presented.
Other:
N.	The divorce is granted on the following ground(s) (check all that apply):
The Plaintiff and Defendant are incompatible.
The Plaintiff and Defendant have lived separate and apart without cohabitation and without
interruption for one year.
The Defendant or Plaintiff had a Spouse living at the time of the marriage.
The Defendant or Plaintiff has been willfully absent for one year.
The Defendant or Plaintiff is guilty of adultery.
The Defendant or Plaintiff is guilty of extreme cruelty.
The Defendant or Plaintiff is guilty of fraudulent contract.
The Defendant or Plaintiff is guilty of gross neglect of duty.
The Defendant or Plaintiff is guilty of habitual drunkenness.
The Defendant or Plaintiff was imprisoned in a state or federal correctional institution at the
time the Complaint was filed.
The Defendant or Plaintiff procured a divorce outside this state by virtue of which she or he
has been released from the obligations of the marriage, while those obligations remain binding
on the Plaintiff or Defendant.
JUDGMENT
Based upon the findings set out above, it is, therefore, ORDERED, ADJUDGED, and DECREED that:
FIRST: DIVORCE GRANTED
A divorce is granted, and both parties shall be released from the obligations of their marriage except for
those obligations listed below or as set out in the attached Separation Agreement
Shared Parenting Plan Parenting Plan Magistrate’s Decision and/or
Other:
which is incorporated in this entry.
Second: PROPERTY
The parties’ property shall be divided as follows:
A.	The Plaintiff shall have the following items of real estate and personal property, free and clear
from all claims of the Defendant, subject to any indebtedness which the Plaintiff shall pay and from
which the Plaintiff shall hold the Defendant harmless:
B.	The Defendant shall have the following items of real estate and personal property, free and
clear from all claims of the Plaintiff, subject to any indebtedness which the Defendant shall pay
and from which the Defendant shall hold the Plaintiff harmless:
C.	The Plaintiff is awarded the following separate property:
D.	The Defendant is awarded the following separate property:
E.	Other orders regarding property (specify):
F.	Within 30 days the parties will take all necessary steps to transfer legal title and possession of
property and take appropriate actions to implement and effectuate the division of pensions and
retirements.
G.	Other orders regarding transfers:
THIRD: DEBT
The Plaintiff and Defendant’s debts shall be divided as follows.
A.	The Plaintiff shall pay the following debts and shall hold the Defendant harmless from all claims:
B.	The Defendant shall pay the following debts and shall hold the Plaintiff harmless from all claims:
C.	Bankruptcy (select one):
The Court will retain jurisdiction to enforce payment of debt obligations, in the event a party files
bankruptcy, including, but not limited to, the ability to determine the debt assigned is in the nature
of maintenance, necessity or support and is therefore nondischargeable in bankruptcy, and/or
making a future spousal support order, regardless of the spousal support order set forth below
under FOURTH: SPOUSAL SUPPORT.
Nothing in this order shall prevent the Plaintiff and/or Defendant from being fully
discharged from the debts allocated in this order in a bankruptcy proceeding except for any orders
expressly for spousal support and the following debts:
Neither party shall incur liabilities against the other party in the future.
FOURTH: Spousal support
A.	Spousal Support Not Awarded
Neither the Plaintiff nor Defendant shall pay spousal support to the other. The Court shall not
retain jurisdiction, except as set forth above under THIRD: DEBTS.
B.	Spousal Support Awarded
The Plaintiff Defendant shall pay spousal support to the Plaintiff Defendant
in the amount of	$	per month plus 2% processing charge commencing on
and due on the	day of the month.
This spousal support shall continue indefinitely for a period of
The Court shall not retain jurisdiction to modify spousal support.
The Court shall retain jurisdiction to modify the amount duration of the spousal support
order.
C.	Termination of Spousal Support
This spousal support shall terminate sooner than the above stated date upon the Plaintiff’s or the
Defendant’s death or in the event of the following (check all that apply):
The cohabitation of the person receiving support in a relationship comparable to marriage.
The remarriage of the person receiving support.
Other (specify):
D.	Method of Payment of Spousal Support:
The spousal support payment, plus 2% processing charge, shall be made to the Ohio Child
Support Payment Central, P. O. Box 182372, Columbus, Ohio 43218-2372, as administered
through the	Hamilton	County Child Support Enforcement Agency by income
withholding at the party’s place of employment.
E.	Other orders regarding spousal support (specify):
F.	Arrearage
Any temporary spousal support arrearage will survive this judgment entry.
Any temporary spousal support arrearage will not survive this judgment entry.
Other:
FIFTH: NAME
is restored to
the prior name of:
SIXTH: Allocation of parental rights and responsibilities
A.	Parental rights and responsibilities shall be allocated as follows:
Plaintiff shall be the residential parent and legal custodian of the following minor child(ren):
Defendant shall be the residential parent and legal custodian of the following minor child(ren):
Plaintiff Defendant shall have parenting time with the minor child(ren) who is/are not
residing with him/her according to the attached schedule.
The parents have entered into a Shared Parenting Plan or Parenting Plan which has been filed
with the Court and is adopted by the Court.
B.	Relocation Notice
Pursuant to section 3109.051(G) of the Revised Code:
If the residential parent intends to move to a residence other than the residence specified in the
court order, the parent shall file a notice of intent to relocate with this Court. Except as provided
in divisions (G)(2), (3), and (4) of section 3109.051 of the Revised Code, the Court shall send a
copy of the notice to the parent who is not the residential parent. Upon receipt of the notice, the
Court, on its own motion or the motion of the parent who is not the residential parent, may
schedule a hearing with notice to both parents to determine whether it is in the best interests of
the child(ren) to revise the parenting time schedule for the child(ren).
The obligation under this notice applies to both parents in a Shared Parenting Plan.
The non-residential parent shall inform the Court and other parent in writing of changes in
address and telephone, including cellular telephone number, unless otherwise provided by court
order.
The residential parent shall inform the Court and other parent in writing of changes in
address and telephone, including cellular telephone number, unless otherwise provided by court
order.
The relocation notice must be filed with the Court that granted the divorce and allocated
parental rights and responsibilities (print name and address of Court):
Hamilton County Domestic Relations Court 800 Broadway Cincininati Ohio, 45202
Other orders:
C.	Records Access Notice
Pursuant to sections 3109.051(H) and 3319.321(B)(5)(a) of the Revised Code:
Subject to sections 3125.16 and 3319.321(F) of the Revised Code, the parent who is not the
residential parent is entitled to access to any record that is related to the child(ren), and to
which the residential parent is legally provided access under the same terms and conditions as
the residential parent. Any keeper of a record who knowingly fails to comply with any record
access order is in contempt of court.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding records access are as follows:
D.	Day Care Access Notice
Pursuant to section 3109.051(I) of the Revised Code:
In accordance with section 5104.11 of the Revised Code, the parent who is not the residential
parent is entitled to access to any day care center that is or will be attended by the child(ren)
with whom parenting time is granted, to the same extent that the residential parent is granted
access to the center.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding day care access are as follows:
E.	School Activities Access Notice
Pursuant to section 3109.051(J) of the Revised Code:
Subject to section 3319.321(F), the parent who is not the residential parent is entitled to access
to any student activity that is related to the child(ren) and to which the residential parent is
legally provided access, under the same terms and conditions as the residential parent. Any
school employee or official who knowingly fails to comply with this school activities access
order is in contempt of court.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding school activities access are
as follows:
SEVENTH: CHILD SUPPORT WITH PRIVATE HEALTH INSURANCE The Obligor pays child support and the Obligee receives child support. is the Child Support Obligor. is the Child Support Obligee. The full name and date of birth of each child subject to this child support order includes the: following: [INSERT name of parent(s) providing private health insurance], who is the [INSERT Child Support Obligor/Obligee/or both if both provide insurance] provides private health insurance for the parties’ child(ren) that is accessible through a group policy, contract, or plan. Private health insurance is reasonable in cost or is provided in accordance with R.C. 3119.302(A)(2). Based upon the evidence presented to the Court and The Child Support Worksheet attached hereto and incorporated herein, the Court finds that it is in the best interest of the parties’ child(ren) that effective [INSERT effective date of child support order], the Obligor, [INSERT name of parent paying child support], will pay child support to [INSERT name of parent receiving child support], Obligee, payable through The Office of Child Support of The Department of Job and Family Services for the parties’ child(ren) as follows:
Current child support per month, per child (before processing fee) $ Combined current child support (before processing fee) $ Current cash medical support obligation per month, per child (before processing fee) $ Combined cash medical support (before processing fee) ** $ Child support arrearage payment per month (before processing fee) $ 2% Processing Fee on TOTAL monthly order $ TOTAL MONTHLY ORDER: $ Deviation (SELECT only the applicable paragraphs): a. The Child Support Obligor’s obligation for child support is deviated by [INSERT percent of deviation or dollar amount of deviation here] [circle appropriate choice] the Child Support Obligor’s cash medical support obligation is deviated by [INSERT percent of deviation or dollar amount of deviation here]. The Obligor’s child support [circle appropriate choice] cash medical support obligation(s) deviate(s) from the actual annual obligation on the child support worksheet attached hereto because, pursuant to R.C. 3119.23 (A) through (Q), the actual annual obligation is unjust, inappropriate and not in the best interest of the parties’ child(ren) for the following reasons: [INSERT deviation factor(s) here pursuant to R.C. 3119.23 (A)—(Q)]. AND/OR (which may be in addition to factors considered pursuant to R.C. 3119.23(A)-(Q)) b. The Child Support Obligor has parenting time ordered by the Court that equals or exceeds 90 overnights per year and is entitled to a 10% reduction as identified on Line 24 of the attached Child Support Worksheet, pursuant to R.C. 3119.231(A); OR The Child Support Obligor has parenting time ordered by the Court that equals or exceeds 147 overnights per year and the Court has determined the deviation for Obligor’s parenting time shall be [INSERT percent of deviation or dollar amount of deviation here] as shown on Line 24 of the attached Child Support Worksheet, pursuant to R.C. 3119.23(B). OR c. The Child Support Obligor’s obligation for child support and cash medical support medical support do not deviate from the actual annual obligation on the child support worksheet attached hereo. [If there is NO deviation and over 90/147 overnights for the Obligor, pursuant to R.C. 3119.23 identify the facts that are the basis for a deviation not being granted]:

Any credit or arrearage of child support or spousal support on the Child Support Enforcement Agency (CSEA) records is preserved.

Notwithstanding Section 3109.01 of the Revised Code, the parental duty of support to children, including the duty of a parent to pay support pursuant to a child support order shall continue beyond the child's eighteenth birthday only in accordance with Section 3119.86 of the Revised Code. The duty of support shall continue during seasonal vacations. Child Support Obligor is responsible for making payments directly to The Office of Child Support of The Department of Job and Family Services until such time as a deduction order takes effect. Any payment made directly to the Child Support Obligee and not through The Office of Child Support of The Department of Job and Family Services shall be deemed a gift and not credited to the support account.

All support under this order shall be withheld or deducted from the income or assets of the Child Support Obligor pursuant to a withholding or deduction notice or appropriate order issued in accordance with Chapters 3119, 3121, 3123, and 3125 of the Revised Code or a withdrawal directive issued pursuant to sections 3123.24 to 3123.38 of the Revised Code and shall be forwarded to the Child Support Obligee in accordance with Chapters 3119, 3121, 3123 and 3125 of the Revised Code. A person and/or entity required to comply with withholding or deduction notices described in Section 3121.03 of the Revised Code shall determine the manner of withholding or deducting from the specific requirement included in the notices without the need for any amendment to the support order, and a person required to comply with an order described in sections 3121.03, 3121.04 to 3121.06 and 3121.12 of the Revised Code shall comply without need for any amendment to the support order. The withholding or deduction noticed and other orders issued under sections 3121.03, 3121.04 to 3121.06 and 3121.12 of the Revised Code, and the notices that require the obligor to notify the Child Support Enforcement Agency administering the support order of any change in the obligor’s employment status or of any other change in the status of the obligor’s assets, are final and enforceable by the Court.

Payments to Child Support Payment Central (“CSPC”) must be sent to the following address: Ohio CSPC, P. O. Box 182372, Columbus, Ohio 43218-2372. Payments may be made by personal check, certified check, cashier’s check, or money order. The payment must include the Court case number [INSERT the case number here] and the SETS number [INSERT the SETS number here]. If the SETS number is not available, then the payment must include Obligor’s Social Security number.

Regardless of the frequency or amount of the support payments, The Office of Child Support of The Department of Job and Family Services will administer the order on a monthly basis in accordance with R.C. 3121.51 to 3121.54. Payments must be made as ordered by the Court.

The Obligee must notify The Child Support Enforcement Agency immediately and the Obligor may notify The Child Support Enforcement Agency of any reason to terminate the support order. A willful failure to notify The Child Support Enforcement Agency is contempt of court. Reasons include but are not limited to the following: a) the child turns 18 years old and no longer attends an accredited high school on a full-time basis, if the support order does not require support to continue past age 18; b) the child’s death, marriage, emancipation, or enlistment in the armed services; or c) the change of legal custody of the child.

EACH PARTY TO THIS SUPPORT ORDER MUST NOTIFY THE CHILD SUPPORT ENFORCEMENT AGENCY IN WRITING OF HIS OR HER CURRENT MAILING ADDRESS, CURRENT RESIDENCE ADDRESS, CURRENT RESIDENCE TELEPHONE NUMBER, CURRENT DRIVER'S LICENSE NUMBER, AND OF ANY CHANGES IN THAT INFORMATION. EACH PARTY MUST NOTIFY THE AGENCY OF ALL CHANGES UNTIL FURTHER NOTICE FROM THE COURT OR AGENCY, WHICHEVER ISSUED THE SUPPORT ORDER.

IF YOU ARE THE OBLIGOR UNDER A CHILD SUPPORT ORDER AND YOU FAIL TO MAKE THE REQUIRED NOTIFICATIONS, YOU MAY BE FINED UP TO $50 FOR A FIRST OFFENSE, $100 FOR A SECOND OFFENSE, AND $500 FOR EACH SUBSEQUENT OFFENSE. IF YOU ARE AN OBLIGOR OR OBLIGEE UNDER ANY SUPPORT ORDER ISSUED BY A COURT AND YOU WILLFULLY FAIL TO GIVE THE REQUIRED NOTICES, YOU MAY BE FOUND IN CONTEMPT OF COURT AND BE SUBJECTED TO FINES UP TO $1,000 AND IMPRISONMENT FOR NOT MORE THAN 90 DAYS.

IF YOU ARE AN OBLIGOR OR OBLIGEE AND YOU FAIL TO GIVE THE REQUIRED NOTICES TO THE CHILD SUPPORT ENFORCEMENT AGENCY, YOU MAY NOT RECEIVE NOTICE OF THE CHANGES AND REQUESTS TO CHANGE THE CHILD SUPPORT AMOUNT, HEALTH CARE PROVISIONS, OR TERMINATION OF THE CHILD SUPPORT ORDER. IF YOU ARE AN OBLIGOR AND YOU FAIL TO GIVE THE REQUIRED NOTICES, YOU MAY NOT RECEIVE NOTICE OF THE FOLLOWING ENFORCEMENT ACTIONS AGAINST YOU: IMPOSITION OF LIENS AGAINST YOUR PROPERTY; LOSS OF YOUR PROFESSIONAL OR OCCUPATIONAL LICENSE, DRIVER’S LICENSE, OR RECREATIONAL LICENSE; WITHHOLDING FROM YOUR INCOME; ACCESS RESTRICTION AND DEDUCTION FROM YOUR ACCOUNTS IN FINANCIAL INSTITUTIONS; AND ANY OTHER ACTION PERMITTED BY LAW TO OBTAIN MONEY FROM YOU TO SATISFY YOUR SUPPORT OBLIGATION.

Definitions: Applicable to Health Expenses and Health Insurance

“Cash Medical.” At this time, the State of Ohio recognizes that parents spend an average of $388.70 per year, per child on uncovered health care expenses. Therefore, the term “cash medical” is defined as $388.70 per child, per year (as amended by statute), and the responsibility for paying this expense is allocated between the parents by income shares, as identified on Line 23 of the child support worksheet.

“Cash medical support” means a dollar amount ordered to be paid in a child support order towards “ordinary medical expenses” incurred on behalf of the children identified in the parties’ child support order during a calendar year. The child support recipient’s share (Obligee) remains in his/her household, while the child support payor’s share (Obligor) is paid to the Obligee in conjunction with the child support amount ordered, ** unless the child is receiving government provided healthcare at no cost to either parent.

“Ordinary medical expenses” include copayments, deductibles and uninsured/unreimbursed medical-related costs for the children named in the child support order.

“Extraordinary medical expenses” include any uninsured/unreimbursed medical-related costs incurred for a child named in the child support order that exceed the total cash medical support amount, including the monthly amount that is Obligee’s share, as identified on line 28 of the child support worksheet.

“Reasonable cost for health insurance” means that a plan of health insurance for the child(ren) identified in the child support order is accessible to the parent ordered to provide health insurance coverage at a cost of 5% or less of his/her gross annual income (identified as the “Health Insurance Maximum” on line 8 of the child support worksheet), unless: (a) one or both parties expressly agree to provide such health insurance for the children at a cost exceeding 5% of his/her gross income; or (b) the Court finds that it is in the best interest of the parties’ child(ren) for one or both parents to provide such insurance at a cost exceeding 5% of his/her gross income as such insurance coverage will not impose an undue financial burden on the parent(s).

Provision of Health Insurance for the Child(ren)
Select the appropriate choice:
a.	One or both parents has/have private, accessible health insurance available for the
child(ren) subject to the child support order at a reasonable cost (of 5% or less of his/her gross
income); or
b.	Despite exceeding a reasonable cost of 5% of his/her gross income(s),
[INSERT name(s) of parents agreeing to provide
such insurance] have/has agreed that
[INSERT name(s) of parents agreeing to provide such insurance] shall obtain or maintain
private health insurance for the children; or
c.	Despite exceeding reasonable cost of 5% of his/her gross income(s), the Court has
determined that it is in the best interest of the child(ren) and that the cost of providing private
health insurance coverage will not impose an undue financial burden on the parent(s);
therefore,	[INSERT name(s) of parents being ordered to
ordered to provide such insurance] shall obtain or maintain private health insurance for the
children.
d.	-AND- include the following for choice a, b or c: Pursuant to R.C. 3119.30, it is hereby
ordered that no later than thirty (30) days after this issuance of this Order,
[INSERT name of party ordered or agreeing to maintain a
plan of health insurance] shall maintain private health insurance for the child(ren) named in the
child support order so long as this parent continues to have private health insurance
coverage available at a reasonable price for the child(ren). A Qualified Medical Child Support
Order shall issue.
-AND- (regardless whether you select paragraph 1 or 2 above) This Order shall remain
in effect for each child identified in the parties’ child support order until each such child
reaches the age of eighteen (18) and no longer attends an accredited high school on a full-time
basis unless otherwise ordered. Except in cases in which a child support order requires the
duty of support to continue for any period after the child reaches age nineteen, the order shall
not remain in effect after the child reaches age nineteen.

Payment of Uninsured/Unreimbursed Extraordinary Medical Expenses

Both parents are liable to all health care providers for their child(ren)’s uncovered extraordinary health care expenses as defined herein according to the formula set forth below.

The Child Support Obligee [INSERT name of Obligee] is responsible for paying the first $388.70 per year, per child for the child(ren)’s uninsured/unreimbursed health care expenses [This amount will be modified if there is a deviation in cash medical support, to correspond with the amount of the deviation as identified on lines 27 and 28 of the child support worksheet. A 100% deviation will result in the parents paying all uncovered health expenses proportionally, as all such expenses would be “extraordinary.” Obligee should only be responsible for paying a certain amount, per year, per child, if that amount is paid as cash medical support (amount will include both parties’ shares)].

The remaining costs of any and all extraordinary medical expenses, including but not limited to, uninsured/unreimbursed medical, dental, orthodontic, optical, prescription, psychological, counseling or psychiatric expenses, including deductibles and/or co-payments under the health insurance plan for the child(ren), shall be paid % by the Child Support Obligor, [INSERT name of Obligor] and % by the Child Support Obligee, [INSERT name of Obligee].

Each parent must submit to the other parent copies of all medical bills and receipts for payment as soon as each parent is in receipt of the bill/receipt. Each parent must submit copies of all bills (including expenses for which the submitting parent is responsible) so the other parent is aware of what expenses have been incurred and what expenses have been paid. Each parent should have a complete set of all the medical bills and receipts. Documentation of all such expenses shall be provided to the other parent and reconciliation of the amounts owed for reimbursement shall occur on a quarterly basis (the last day of January, April, July, and November each year).

If one parent has paid the bill in full, the other parent must pay his/her share to the parent who paid the bill within 30 days after he/she receives the receipts. If the health care provider has not been paid in full, each parent must make arrangements with the health care provider to pay his/her share within 30 days of the date that he/she receives the bill. If the bill is later reduced for any reason (insurance payment, insurance company modification, etc.), the parent who first learns of the reduction must notify the other parent immediately. Each parent’s portion of the original bill will be reduced accordingly, based on the percentage of each parent’s responsibility for the original bill. Neither parent may use the child(ren) to deliver medical bills, proof of payment, or reimbursement to the other parent.

Pursuant to Ohio Revised Code Sect. 3119.30, the parent(s) ordered to provide private health insurance for the child(ren) shall, not later than thirty (30) days after the issuance of the order herein, supply the other parent with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under the health insurance coverage and a copy of any necessary insurance cards.

EIGHTH: TAX EXEMPTION
Income tax dependency exemptions (check all that apply):
A.	The Plaintiff shall be entitled to claim the following minor child(ren) for all tax purposes
for even-numbered tax years odd-numbered tax years all eligible tax years, so long
as the Plaintiff is substantially current in any child support the Plaintiff is required to pay as of
December 31 of the tax year in question:
The Defendant shall be entitled to claim the following minor child(ren) for all tax purposes
for even-numbered tax years odd-numbered tax years all eligible tax years, so long
as the Defendant is substantially current in any child support the Defendant is required to pay
as of December 31 of the tax year in question:
B.	Other orders regarding tax exemptions (specify):
If a non-residential parent is entitled to claim the child(ren), the residential parent is required to
execute and deliver Internal Revenue Service Form 8332, or its successor, together with any other
required forms as set out in section 152 of the Internal Revenue Code, as amended, on or before
February 15th of the year following the tax year in question, to allow the non-residential parent to
claim the minor child(ren).
NINTH: OTHER ORDERS

TENTH: COURT COSTS
Court costs shall be (select one):
Taxed to the deposit. Court costs due above the deposit shall be paid as follows:
Other (specify):

ELEVENTH: Clerk of Courts
The Clerk of Courts shall provide:
a certified copy to:
a file stamped copy to:
Notice. Pursuant to Civil Rule 58(B), the Clerk is directed to serve upon the parties a notice of the
filing of this Judgment Entry and of the date of entry upon the Journal.
Date	Judge

2