Instructions for Complaint for Divorce with Minor Children
Background
The “Complaint” is the basic document of all lawsuits and has two purposes. When filed with the court
and delivered to your spouse, the Complaint formally begins the lawsuit. Furthermore, the Complaint provides
your spouse and the court with an understanding of the issues in the case and the results you’re seeking. The
Complaint for Divorce must be filed with the court and delivered to your spouse in every case. Type or print
in black or blue ink.
After you have filed your complaint for Divorce, you must appear at the Child Support
Enforcement Agency with the following forms completed: 1. THE APPLICATION FOR CHILD
SUPPORT SERVICES NON-PUBLIC ASSISTANCE APPLANT, AND 2. THE AFFIDAVIT FOR
ESTABLISHMENT OR REVIEW OF A CHILD SUPPORT ORDER, which are included below, and
have a child support calculation completed and then file it with the Clerk of Courts.
Lastly, Instructions for Service and Instructions for Service Form must be filled out so notice of
your divorce and other requests can be sent to your spouse by the Clerk of Courts Office.
Holmes County Court of Common Pleas
Domestic Relations Division
NEW CASE DESIGNATION FORM
For Official Use Only:
Case No.: ______________
SETS No.: ______________
Instructions: Pursuant to Local Rules, this form must be completed and submitted with any new cause of action filed with the Holmes
County Clerk of Courts. The Social Security Numbers will NOT be public record.
Case Type:
(e.g. dissolution, dissolution with children, divorce, divorce with children, parentage, visitation rights, etc.)
Plaintiff Information:
First
Name:
Last
Name:
Address:
City:
SSN:
Telephone:
(if unrepresented)
Middle
Initial:
Suffix:
State:
Zip:
DOB:
Defendant Information:
First
Name:
Last
Name:
Address:
City:
SSN:
Telephone:
(if unrepresented)
State:
Middle
Initial:
Suffix:
Zip:
DOB:
□ Pro Se
Plaintiff Attorney Information:
Attorney Name:
Ohio Sup Ct #:
Telephone:
Defendant Attorney Information: (if known)
Attorney Name:
Ohio Sup Ct #:
Telephone:
Firm Name:
Address:
Firm Name:
Address:
City:
State:
Zip:
City:
State:
Child Information:
1st Child Name:
DOB:
SSN:
Address:
City:
State:
2nd Child Name:
DOB:
SSN:
Address:
City:
State:
3rd Child Name:
DOB:
SSN:
Address:
City:
State:
** If additional space is needed to list children related to these proceedings, attach additional forms.
Zip:
Zip:
Zip:
Zip:
__________________________________________
Attorney for Plaintiff (or pro se litigant)
IN THE COURT OF COMMON PLEAS
DOMESTIC RELATIONS DIVISION
HOLMES COUNTY, OHIO
Petitioner/Plaintiff
vs.
CASE NO.
JUDGE ROBERT D. RINFRET
Petitioner/Defendant/Respondent
MOTION TO PROCEED
WITHOUT ADVANCING A FILING FEE
DEPOSIT
Now comes
Petitioner/Plaintiff/Defendant/Respondent in the above-captioned case, and hereby moves this court for an order allowing him/her to
proceed without advancing a filing fee deposit. As basis for this Motion, I hereby state that I am financially unable to pay the filing fee
at the time of filing and that my financial circumstances are outlined in the Indigency Affidavit being filed with this Motion. I
understand that this court cannot waive the payment of filing fees, and that said fees must be paid by one of the parties. I agree to
ensure that arrangements are made with the clerk of courts for payment of filing fees upon assessment of costs being ordered by the
court. I further understand that should this court deny this Motion, I must pay the required cost deposit or the case/motion will be
dismissed.
Respectfully Submitted,
Signature
Printed Name
Telephone Number:
IN THE COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
________________________________
Case No. ________________________
Plaintiff,
VS
________________________________
Defendant,
JUDGE _________________________
AFFIDAVIT OF INDIGENCY
STATE OF OHIO:
SS:
COUNTY OF HOLMES
I, ___________________________, being first duly cautioned and sworn as prescribed by law, say that
I own no real property and I have no savings. My sole source of income is ______________ per month. I
therefore have no funds or assets from which to pay the filing fees and other court costs in this case.
____________________________________
Affiant
SWORN to and subscribed in my presence this ____ day of _________, 20______.
____________________________________
Notary Public
IN THE COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
Case No.
________________________________________
NAME OF PLAINTIFF
-DR-
JUDGE ROBERT D. RINFRET
________________________________________
STREET ADDRESS
________________________________________
CITY, STATE, ZIP CODE
Plaintiff
_______________
DATE OF BIRTH
COMPLAINT FOR DIVORCE
WITH MINOR CHILDREN
________________________________________
NAME OF DEFENDANT
________________________________________
STREET ADDRESS
________________________________________
CITY, STATE, ZIP CODE
Defendant
_______________
DATE OF BIRTH
1. Plaintiff has lived in Ohio for at least six (6) months and in Holmes County for more than
ninety (90) days before filing this complaint.
2. Plaintiff and Defendant were married in
____________.
on
3. The parties have children born of this relationship, namely:
Child’s Name
______ __________
Date of Birth
______ __________
Child’s Name
Date of Birth
Child’s Name
______ __________
Date of Birth
______ __________
Child’s Name
Date of Birth
Child’s Name
______ __________
Date of Birth
______ __________
Child’s Name
Date of Birth
Child’s Name
______ __________
Date of Birth
______ __________
Child’s Name
Date of Birth
4. The female spouse
is/
is not currently pregnant.
5. The parties
do not own real estate
do own real estate located at
_____
______________________________________________________________________________.
6. The parties have personal property which
___ has been substantially divided
______ has not been substantially divided.
Major property items include: _____________________________________________________
7. The parties
do not have any debts.
do have some debts, namely: ___________________________________
______________________________________________________________________________
___ ___________________________________________________________________________.
8. As for grounds for divorce, Plaintiff says the marriage is incompatible, but if the Court finds compatibility, then Plaintiff alleges
that the Defendant has been guilty of:
adultery
extreme cruelty
gross neglect of duty
living separately for 1 year
imprisonment in a federal
or state prison
willful absence for one (1) year
fraudulent contract
obtaining a divorce outside of the state
__ habitual drunkenness
having another spouse living at the time
of this marriage (bigamy).
THE PLAINTIFF ASKS THE COURT FOR THE FOLLOWING:
a. That the Court grant this divorce;
b. That the Court equitably divide the property and debts;
c. That the Court:
designate the Plaintiff the residential parent and legal custodian of the
minor children, both temporarily and permanently.
order the Defendant to pay child support during the case and as part of the final orders, the child support worksheet
is attached.
restrain the Defendant from disposing of property during this action.
_______ order the Defendant to pay spousal support.
d. To restore the plaintiff to the former or maiden name of: ________________________.
e. That the Court order the Defendant to pay the costs of this action; and
f. That the Court awards any other relief it deems fair and equitable.
RESPECTFULLY SUBMITTED,
____________________________________________
Signature of plaintiff
_______________________________________
Print Name
_____________________________________________
Street Address
_____________________________________________
City
State
Zip
**** NEEDS INSTRUCTIONS FOR SERVICE
Instructions for Motion and Affidavit for Temporary Orders with Minor Children
Background
A “motion” is a request made to a court. Courts generally make orders or judgments at the conclusion of a lawsuit.
However, in divorce cases, the law recognizes the need for stability during the time the case is awaiting trial. The Motion for
Temporary Orders formally asks the court to make orders governing your relationship with your spouse until the case becomes final.
For example, if you have minor children with your spouse, then you may want the court to declare you the temporary “residential
parent” (custody) so that there is no confusion about where the children will be living and who has the authority to act on their behalf
with doctors, schools, and others.
If you need temporary orders, then you must file the Motion for the court to consider your requests. You should file the
MOTION and supporting documents at the beginning of the case.
Completing the Motion and Affidavit for Temporary Orders with Minor Children
Caption: Print your full name above the word plaintiff and print your spouse’s full name above the word defendant. Leave
blank the case number and the name of the judge until you file the case at the Clerk’s office.
General Instructions: Read through the ten numbered paragraphs and then place a check mark on the line in front of each
item that applies to your situation.
Paragraphs 1-4. Custody, Parenting time & Child Support: It is generally advisable to secure temporary custody and
child support. In Ohio, custody is called “residential parent” or “residential parent and legal custodian.” Five documents must be
completed and filed to be declared the temporary residential parent: (1) this MOTION; (2) INFORMATION FOR PARENTING
PROCEEDING AFFIDAVIT; (3) AFFIDAVIT IN SUPPORT; (4) the Child Support Computation Worksheet; and (5) JUDGMENT
ENTRY/MAGISTRATE’S ORDER.
Temporary custody and child support are commonly granted without a court hearing where: (1) the parents no longer live
together; (2) the children live with you; and (3) all five of the documents are properly completed and filed. But if the children are not
living with you and you desire to be the residential parent, then make your request by filing the five documents. The court will
probably schedule a hearing on the matter since you are seeking to change the location of the children’s residence.
Note that it is unlawful to terminate health insurance coverage for children or a spouse during the time the case is in process.
Once the case is concluded, both parents, generally, will be obliged to secure or maintain health insurance for the minor children.
Generally speaking even if you are designated the temporary residential parent, your spouse will have visitation rights (also
called companionship or parenting time)with the children. If there is a good reason it would not be in your children’s best interest for
your spouse to visit with the children, you must indicate that in paragraph 3 and state the reason in paragraph 3 of the AFFIDAVIT.
Paragraph 5. Spousal Support: “Spousal support,” formerly called alimony, is defined as “any payment or payments to be
made to a spouse or former spouse, or to a third party for the benefit of a spouse or a former spouse, that is both for sustenance and for
support of the spouse or former spouse.” Spousal support may take the form of a sum of money, installment payments, or real or
personal property. Spousal support (temporary or permanent) is not granted routinely and, therefore, the reasons must be clearly
stated in the AFFIDAVIT.
There are no absolute, objective standards for deciding whether or not spousal support should be awarded and, if so, how
much and for how long. In deciding these issues, courts look at many factors including: (1) income of the parties; (2) earning
abilities; (3) ages and physical, mental, and emotional conditions of the parties; (4) retirement benefits; (5) length of the marriage;
(6) to what extent custody of children limits earning ability; (7) standard of living during the marriage; (8) educational levels; (9)
assets and debts; (10) the contribution of each to the education, training, or earning ability of the other; (11) the time and expense
needed to acquire education or job experience to acquire appropriate employment; and (12) tax consequences of spouse support on
each party. This list is not exhaustive. The general tendency is not to award spousal support where the marriage is of short duration.
If, after reviewing these factors, you believe you are entitled to spousal support, check the line in front of paragraph 5 and state the
reasons in paragraph 4 of the AFFIDAVIT. Consider seeking legal assistance on this issue.
Paragraph 7. Possession of Home: If you fear that your spouse will attempt to enter your home or attempt to move back in,
then you may place a check mark on the line in front of paragraph 7. Granting temporary possession of the home (which is different
from ownership) applies to all types of housing; rental, home ownership, land contracts. It is important for the court to know if your
spouse has another place to live if he/she is excluded from the marital residence.
If there is a concern about keeping up the payments (rent or mortgage), then use paragraph 9 to cover the payment issue and
paragraph 7 of the MOTION and paragraphs 7 & 8 of the AFFIDAVIT to secure possession of the home.
Paragraph 8. Possession of Automobile: If you need a family vehicle, then place a check mark on the line in front of
paragraph 8, and type a description of the car. If the court grants your request, you will have exclusive use of the car (which is
different from ownership) until the case is final. This request is easier for the court to grant where there are two cars; one for each
spouse. Where there is only one vehicle (no matter whose name is on the title), clearly state your need in paragraphs 9-11 of the
AFFIDAVIT (for example, you need the car to get to work and to transport the children living with you).
Paragraph 9. Ongoing Payment of Debts: A request for an order compelling your spouse to pay ongoing expenses while the
case is in process is not routinely granted. Therefore, clearly state the need for this request in paragraph 12 of the AFFIDAVIT.
Paragraph 10. Restraining Order: If you need to prevent your spouse from contacting or visiting you at work, your
residence, or by phone, place a check mark on the line in front of paragraph ten. A spouse may become annoying, manipulative or
demanding once he/she becomes aware that a divorce has been filed. If your spouse engages in physical acts of violence or threats,
you may need to secure a Civil Protection Order. Forms are available at the Clerk of Courts and Every Woman’s House (330) 2636021 will provide assistance in gaining a temporary order. If the conduct is “low grade” and disturbs your routine at work or home,
the Court will restrain your spouse from contacting you.
Paragraph 11. Disposing of Property and Incurring Debt: If you are concerned that your spouse will sell or dispose of
property (such as household goods or furnishings), then place a check mark in front of paragraph 3. This request is granted routinely.
You should also check this number if you are concerned that your spouse may try to secure credit in your name or continue to use an
existing joint credit account.
Signature & Address: Sign the MOTION at the bottom of the page, then print your name and address. Because this is not
an affidavit, it does not need to be signed in front of a notary.
In the event that you are unable to complete the child support guidelines you are required to fill out Form #12 in
order that the child support bureau can assist you in receiving child support payments.
In the event that you wish to consider a shared-parenting plan or visitation schedule please review Forms # 16 and
#17. In addition, a blank separation agreement (Form #19) has been provided. In order to have a shared-parenting plan and
a separation agreement the plaintiff and defendant must agree to the terms and conditions contained in those plans or
agreements.
IN THE COURT OF COMMON PLEAS, HOLMES COUNTY, OHIO
DOMESTIC RELATIONS DIVISION
_________________________
_________________________
CASE NO. ____________________
_________________________
JUDGE ROBERT D. RINFRET
DOB_____________________
Plaintiff,
v.
_________________________
_________________________
MOTION FOR TEMPORARY
_________________________
ORDERS WITH CHILDREN
DOB_____________________
- Plaintiff; - Defendant, pro se, asks this Honorable Court for the following temporary orders, for the reasons
set forth in the attached affidavit:
1. Designation of - Plaintiff; -Defendant as the temporary residential parent and legal custodian of the
following minor child(ren) (include dates of birth):
_____________________________________-DOB:____________________________________
_____________________________________-DOB:____________________________________
_____________________________________-DOB:____________________________________
_____________________________________-DOB:____________________________________
2.
- Plaintiff;
-Defendant asks that the opposing party have visitation/parenting time as follows:
____________________________________________________________________________________
____________________________________________________________________________________
3.
- My spouse should not have visitation/parenting time with the children.
4.
- An order requiring my spouse to pay temporary child support.
5.
- An order requiring my spouse to pay temporary spousal support.
6.
- An order requiring my spouse to pay me money for attorney’s fees pursuant to R.C. 3105.73 so
that I can hire an attorney.
7.
- Possession of the house and land located at: __________________________________________
_____________________________________________________________________________________
8.
- Possession of the following motor vehicle: ____________________________________________
9.
- An order requiring my spouse to pay the following bills and/or debts:
_____________________________________________________________________________________
_____________________________________________________________________________________
10.
- A temporary restraining order prohibiting my spouse and me from injuring, threatening, harassing, or
physically abusing each other.
11.
- A temporary restraining order prohibiting my spouse and me from damaging, destroying, selling or
attempting to sell, disposing of, or removing marital property and/or the child(ren)’s personal property
from each other’s residences or incurring debts in Plaintiff’s or Defendant’s name for which the other may
be held liable.
Respectfully submitted,
_____________________________________________
Plaintiff/Defendant
IN THE COURT OF COMMON PLEAS, HOLMES COUNTY, OHIO
DOMESTIC RELATIONS DIVISION
Case Number:
Plaintiff,
vs.
Judge: Robert D. Rinfret
Defendant.
AFFIDAVIT IN SUPPORT OF MOTION FOR
TEMPORARY ORDERS WITH CHILDREN
STATE OF OHIO,
SS:
COUNTY OF
Plaintiff __________________, pro se, being duly cautioned and sworn, states:
1.
My spouse and I separated on or about ______________. Since we separated, the children have
lived:
2.
It is in the child(ren)’s best interest that I be designated the temporary residential parent and legal
custodian and/or that parenting time be ordered as requested for the following reasons:
3.
It is not in my child(ren)’s best interests for my spouse to have visitation with the children for the
following reasons:
4.
I need temporary spousal support because:
5.
It would be equitable for my spouse to pay my attorney’s fees and litigation expenses because
(include income information, other expenses, conduct of the other party, or any other relevant factor):
6.
I have contacted one or more attorneys and it would cost me______________________
to hire an attorney to represent me in this divorce.
7.
I need temporary possession of our residence because:
8.
My spouse is staying at and with/can stay at and with:
9.
I need the _______________________ car/truck because:
10.
11.
My spouse has another car/truck which he can drive.
My spouse does not need a car/truck because:
12.
I am asking that my spouse pay the debts in paragraph 9 of the Motion (Form #7-Motion for
Temporary Orders with Children) because:
13.
14.
Unless restrained, my spouse may injure, threaten, harass, or physically abuse me.
Unless restrained, my spouse may damage, destroy, sell or attempt to sell, dispose of, or remove
marital property and/or my or the child(ren)’s personal property from my residence, or incur debts
for which I may be held liable.
FURTHER AFFIANT SAYETH NAUGHT. ________________________________________
Plaintiff/Defendant
SWORN TO AND SUBSCRIBED before me, this ______ day of ____________________, 20___.
____________________________________NOTARY PUBLIC
IN THE COMMON PLEAS COURT OF HOLMES COUNTY, OHIO
DIVISION OF DOMESTIC RELATIONS
FINANCIAL AFFIDAVIT FOR COMPUTATION OF CHILD SUPPORT AND MEDICAL SUPPORT
___________________________________
Plaintiff/Petitioner (1)
Address: ___________________________
___________________________________
Phone: ____________________
CASE NO. _________________________
Attorney: ___________________________
Attorney Address: ____________________
___________________________________
Attorney Phone: _____________________
JUDGE ROBERT D. RINFRET
V.
__________________________________
Defendant/Petitioner (2)/Respondent
Address: ___________________________
___________________________________
Phone: ____________________
___________________________________
(Your Name)
Date of Prior Decree: ________________
(if applicable)
Attorney: ___________________________
Attorney Address: ____________________
___________________________________
Attorney Phone: _____________________
Notes: In accordance with Local Rules of this court, this affidavit must be filed by each party with every case that
concerns minor children, regardless of whether child support or medical support will be paid. You will be required to
provide proof of income per local rule and O.R.C. 3119.05. You are under a continuing legal duty to file an updated
version of this form if you learn of any additional information. If more space is needed, attach additional page(s).
I. Information Required for Support Calculation:
A. Minor or Dependent Children in This Case (Include adopted children and any child of the parties who is over 18 and
handicapped)
Child’s Name
Date of Birth
B. Other Minor Children Living in My Household
Child’s Name
Date of Birth
Male /
Female
Age
Residing with
Male /
Female
Age
Relationship
C. Other Minor Children of Mine, Not Living in My Household
Child’s Name
Date of Birth
Male /
Female
Age
Residing with
II. Child Support Guideline Adjustment:
Father
(All Figures Per
Year)
Court ordered child support you pay for other
child(ren) in another case
Case Number where support ordered
Date of initial order
Court ordered spousal support you pay to a
former spouse
Number of your other dependent children
living with you from a different marriage or
relationship
Is the other parent of any of your other
children also in your household?
If yes, how many children do you have with the
parent who lives with you?
Court ordered child support you receive for the
dependent child(ren) you indicated on the line
above (other parent not in home)
Child care expenses you pay for child(ren) of
this case (employment or educational-related)
Local income taxes paid or rate of tax where
you live or work
Self-Employment Tax (5.6% of A.G.I.)
Private health insurance cost to you for your
children (family plan cost less individual plan
cost)
Total number of dependents covered by your
insurance
Yes
$
No
or
Yes
% $
Father
(All Figures Per
Year)
Any non-means tested benefits received by a
child subject to this support order due to the
death, disability, or retirement of the parent.
This includes SSD, or Veteran’s benefits
Mother
(All Figures Per
Year)
No
or
Mother
(All Figures Per
Year)
%
III. Income [As defined in O.R.C. 3119.01(C)]:
A. Gross Yearly Income from Employment (If not known, please estimate. Put “EST” after each estimated figure.)
Father
Mother
Gross yearly employment income
Employer
Payroll Address
City, State, Zip
Number of paychecks per year
□12
□ 24
□ 26
Year-to-date Gross Income
□ 52
Through
date of
□12
□ 24
□ 26
□ 52
Through
date of
Prior Year’s Tax Refund
B. Annual Overtime, Commissions, Bonuses (If not known, please estimate. Put “EST” after each estimated figure.)
Father
Mother
Overtime,
Year3 is Most Base
Year3 is Most
Commission,
Base Income Overtime, Commission, Bonuses
Recent Year
Income
Recent Year
Bonuses
_____ Year 1
_____ Year 1
_____ Year 2
_____ Year 2
_____ Year 3
_____ Year 3
Y-T-D This
Year
Through:
D. Gross Self-Employment Income (If not known, please estimate. Put “EST” after each estimated figure.) Use Gross Annual
Figures for Most Recent Full Year. See O.R.C. 3119.01(C)
Father
Mother
Business
Receipts
Ordinary &
Necessary
Business
Expenses
Net Business
Income
D. Other Income All other income, actual or expected, including pension, social security, workers compensation, commissions,
royalties, disability benefits, trust income, annuities, reoccurring capital gains, unemployment benefits, rents, expense-sharing,
dividends, interest, AFDC, SSI, food stamps, spousal support received from a prior spouse, etc. (If not known, please estimate. Put
“EST” after each estimated figure.)
Father
Mother
Describe
Per Year
Describe
Per Year
E. Total Annual Income
Father
Total Gross Annual Income
Total average gross monthly income
Average monthly deductions
Total net monthly income
Mother
F. Benefits of Employment (Use of company car, country club memberships, stock options, etc.)
Father
Mother
Benefits
Values
Benefits
Values
IV. Private Health Insurance Information
CHECK ALL APPLICABLE BOXES AND FILL-IN ALL BLANKS.
My child(ren is/are covered by low-income government –assisted health care coverage (Healthy
Start/Medicaid, etc.)
________________________________________________________________
LIST OF PLANS
I have the following private health insurance policies, contracts or plans to cover the child(ren) available to
me.
Name of Insurance
Company
Entity/group through which policy, contract, or plan is
available
NO PRIVATE HEALTH INSURANCE
I DO NOT HAVE the child(ren) enrolled in private health insurance because:
_ health insurance is not available through my employer or another group policy, contract or plan that will cover the
children.
_ I declined enrollment of the child(ren) in health insurance available through my employer or another group policy,
contract or plan, but I am enrolled in a policy, contract or plan for myself.
_ I am not yet eligible to enroll in private health insurance through employment or another group policy, contract or plan,
but I will become eligible on (month/day/year) ____/____/______.
_ I expect to enroll the child(ren) when I become eligible.
_ OTHER reason the child(ren) is/are not enrolled (explain):
_____________________________________________________________________________
CURRENT PRIVATE HEALTH INSURANCE ENROLLMENT
I DO HAVE the child(ren) enrolled in private health insurance through:
_ an individual (non-group) policy, contract or plan.
_ a group policy, contract or plan.
Date child(ren) was/were enrolled in private health insurance: (month/day/year) ____/____/______.
Provided through: _ Employer _ Current Spouse _ Other: ____________________________________________________________
Name of Policyholder: ____________________________
Insurance Co. Name: ____________________________
Policyholder address: ____________________________
Ins. Co. Claims address ____________________________
__________________________________________________
_________________________________________________
Policyholder Phone No. (___) _______________________
Ins. Co. Claims Phone No. (____) _____________________
Name of policy, contract or plan _______________________
Group Number: ___________________________
Identification/subscriber Number: _____________________
ACCESSIBILITY OF PRIMARY CARE SERVICE
My child(ren) has/have primary care services (health care/laboratory services customarily provided by a general
practitioner,
internal medicine, family medicine physician, or pediatrician) accessible with this private health insurance:
_ within 30 miles of the child(ren)’s home.
_ because the child(ren) live(s) in a geographic area where the residents customarily travel farther than 30 miles for their
child(ren)’s primary care services.
_ because primary care services are only accessible by public transportation. (Primary care services are accessible
by public transportation and the person responsible for taking the child(ren) for primary care service is dependent upon
public transportation).
REASONABLENESS OF COST/BEST INTEREST OF CHILDREN CONSIDERATIONS
The cost for private health insurance benefits that cover me and/or my child(ren) or will cover us when I am eligible is: (Do
not include the amount than an employer or other person/entity pays for health insurance.)
Single coverage
$_______________ per month
Single coverage plus one
$_______________ per month
Single coverage plus two
$_______________ per month
Family coverage (unlimited dependents)
$_______________ per month
Other (explain): __________________________ $_______________ per month
_ I want to enroll/continue to have the child(ren) enrolled in the private health insurance plan in which I am currently
enrolled/will become eligible to enroll in even if the cost exceeds 5% of my TOTAL ANNUAL GROSS INCOME
(Health Insurance Maximum).
Number of Dependents currently enrolled or who will be enrolled when I become eligible: _________
Name of Dependent
Relationship to You
________________________________________________ _____________________________
________________________________________________ _____________________________
________________________________________________ _____________________________
________________________________________________ _____________________________
________________________________________________ _____________________________
V. List any additional factors or special circumstances you believe the court
should consider.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
OATH OF AFFIANT
I, _____________________________________(print) hereby swear or affirm that the information set forth in this Affidavit
of Income, Expenses, and Property above is true, complete, and accurate. I understand that falsification of this document
may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of
this document may also subject me to criminal penalties for perjury (O.R.C. 2921.22).
________________________________
AFFIANT
Sworn to and subscribed before me this _____ day of ________________, ______.
________________________________
Notary Public
COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
ROBERT D. RINFRET
v./and
Defendant/Petitioner/Respondent
Instructions: Check local court rules to determine when this form must be filed.
By law, an affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation)
proceeding in this Court, including Dissolutions, Divorces and Domestic Violence Petitions. Each party has a continuing
duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court
in this or any other state. If more space is needed, add additional pages.
PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A))
Affidavit of
(Print Your Name)
Check and complete ALL THAT APPLY:
1.
2.
I request that the court not disclose my current address or that of the child(ren). My address is
confidential pursuant to R.C. 3127.23(D) and should be placed under seal to protect the health,
safety, or liberty of myself and/or the child(ren).
Minor child(ren) are subject to this case as follows:
Insert the information requested below for all minor or dependent children of this marriage. You must list the residences
for all places where the children have lived for the last FIVE years.
a.
Child’s Name:
Place of Birth:
Date of Birth:
Sex:
Period of Residence
to
present
Check if
Confidential
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
Male
Female
Person(s) With Whom Child Lived
(name & address)
Relationship
b.
Child’s Name:
Place of Birth:
Date of Birth:
Sex:
Male
Female
 Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.
Period of Residence
to
c.
present
Check if
Confidential
Person(s) With Whom Child Lived
(name & address)
Relationship
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
Child’s Name:
Place of Birth:
Date of Birth:
Sex:
Male
Female
 Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.
Period of Residence
to
present
Check if
Confidential
Person(s) With Whom Child Lived
(name & address)
Relationship
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
to
Address
Confidential?
IF MORE SPACE IS NEEDED FOR ADDITIONAL CHILDREN, ATTACH A SEPARATE PAGE AND CHECK THIS
BOX .
3.
Participation in custody case(s): (Check only one box.)
I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other
state, concerning the custody of, or visitation (parenting time), with any child subject to this case.
I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other
state, concerning the custody of, or visitation (parenting time), with any child subject to this case. For
each case in which you participated, give the following information:
a.
Name of each child:
b.
c.
d.
Type of case:
Court and State:
Date and court order or judgment (if any):
IF MORE SPACE IS NEEDED FOR ADDITIONAL CUSTODY CASES, ATTACH A SEPARATE PAGE AND
CHECK THIS BOX .
4.
Information about other civil case(s) that could affect this case: (Check only one box.)
I HAVE NO INFORMATION about any other civil cases that could affect the current case, including
any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse
allegations or adoptions concerning any child subject to this case.
a.
I HAVE THE FOLLOWING INFORMATION concerning other civil cases that could affect the current
case, including any cases relating to custody, domestic violence or protection orders, dependency,
neglect or abuse allegations or adoptions concerning a child subject to this case. Do not repeat
cases already listed in Paragraph 3. Explain:
Name of each child:
b.
c.
d.
Type of case:
Court and State:
Date and court order or judgment (if any):
IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS
BOX .
5. Information about criminal case(s):
List all of the criminal convictions, including guilty pleas, for you and the members of your household for the
following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any
domestic violence offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C.
2950.01; and any offense involving a victim who was a family or household member at the time of the offense and
caused physical harm to the victim during the commission of the offense.
Name
Case Number
Court/State/County
Convicted of
What Crime?
IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS
BOX .
6.
Persons not a party to this case who has physical custody or claims to have custody or visitation
rights to children subject to this case: (Check only one box.)
I DO NOT KNOW OF ANY PERSON(S) not a party to this case who has/have physical custody or
claim(s) to have custody or visitation rights with respect to any child subject to this case.
I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical
custody or claim(s) to have custody or visitation rights with respect to any child subject to this case.
a.
Name/Address of Person
Has physical custody
Claims custody rights
Claims visitation rights
Name of each child:
b.
Name/Address of Person
Has physical custody
Claims custody rights
Claims visitation rights
Claims custody rights
Claims visitation rights
Name of each child:
c.
Name/Address of Person
Has physical custody
Name of each child:
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
Notary Public
My Commission Expires:
,
.
APPLICATION FOR CHILD SUPPORT SERVICES
NON-PUBLIC ASSISTANCE APPLICANT
IMPORTANT: If you are receiving ADC or Medicaid, do not complete this application because you became eligible for child
support services when you became eligible to receive ADC or Medicaid.
I the undersigned, _______________________ request Child Support Services from the Holmes County Child Support
Enforcement Agency. I understand and agree to the following conditions:
A.
B.
I am a resident of the County in which services are requested.
Recipients of the child support services shall cooperate to the best of their ability with the CSEA. (See attached rights
and responsibility information).
The Child Support Enforcement Agency can assist you in providing the following services:
1. Location of Absent Parents.
The agency can assist in finding where an absent parent is currently living, in what city, town, or state. The applicant
can request “Location Services Only,” if the sole need is to find the whereabouts of the absent parent.
2. Establishment or Modification of Child Support and Medical Support.
The CSEA can assist you to obtain an order for support if you are separated, have been deserted, or need to
establish paternity (fatherhood). The CSEA can also assist you in changing the amount of support orders
(modification), and to establish a medical support order.
3. Enforcement of Existing Orders.
The CSEA can help you collect current and back child support.
4. Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages.
The agency can assist in collecting back support (arrearages) by intercepting a non-payor’s federal and state income
tax refunds on some cases.
5. Withholding of Wages and Unearned Income for the Payment of Court Ordered Support.
The agency can help you get payroll deductions for current and back child support and can intercept unemployment
compensation to collect child support.
6. Establishment of Paternity.
The agency can obtain an order for the establishment of paternity (fatherhood), if you were not married to the father
of the child. An absent parent may request paternity services.
7. Collection and Disbursement of Payments.
The CSEA can collect the child support for you, and send you a check for the amount of the payments received. Back
support collected will be paid to you until all of the back support you are owed is paid.
If you received ADC in the past and support was assigned to the state, back support collected will be paid to the state
after you receive back support owed to you.
8. Interstate Collection of Child Support.
The agency can assist you in collecting support if the payor is living in another state or in some foreign countries.
C.
D.
The only fee you can be charged for services is a one dollar application fee. Some counties pay this fee for the
applicants.
In providing IV-D services, the CSEA and any of its contracted agents (e.g., prosecutors, attorneys, hearing officers,
etc.) represent the best interest of the children of the state of Ohio and do not represent any IV-D recipient or the IV-D
recipient’s personal interest.
Name
APPLICANT INFORMATION (INFORMATION ABOUT YOU)
Date of Birth
Social Security Number (SSN)
Type(s) of Service(s) Requested: All services listed
Current Marital Status (Check One)
□Single
□Married □Divorced
□Deserted □Widowed
□Separated
Location of absent parent only
Other (please explain)
I understand that the Child Support Agency- within 20 days of receiving this application will contact me by a written notice to
inform me if my case has been accepted for child support services (IV-D Services).
Signature of Applicant
Date
Applicant’s Name (Last, First, Middle)
Telephone Number (Home)
Address (Street/Route, P.O. Box)
(Work)
City, State, Zip Code
INFORMATION ON CHILDREN
Child 1
Child 2
Child 3
Child 4
a. Name
b. Gender
c. SSN
d. Date of Birth (DOB)
e. Name(s) of
Absent Parent
f. Has Paternity (Fatherhood)
Been Established?
g. Is There an Order For Support
□ Yes □ No
ABSENT PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT
Absent Parent #1
Name
Address
(City, State, Zip Code)
SSN
Date of Birth (DOB)
Name of Employer
Address of Employer
(City, State, Zip Code)
Amount of Support
Ordered
(Wk, Bi-Wk, Mo)
Case Number on
Support Order
Date of Support Order
Absent Parent #2
Absent Parent #3
Location Where Order
Was Issued
(City, County, State)
Military Service
Give Date and Branch
Entered
Arrest Record: Give Date
and Place of Arrest
If the absent parent has
been on Public Assistance:
Give Date and Place
Give Name and Address
of Current Spouse
of Absent Parent
Have you ever been on public assistance?
When (Date)
□ Yes
□ No
Where (City and State)
County
FOR AGENCY USE ONLY
Case Name
Date Requested
Date Mailed or Provided
Case Number
Date Returned or File Date
Holmes County Child Support Enforcement Agency
PO Box 72
Millersburg, Ohio 44654
330-674-1111
800-971-7979
Fax: 330-674-0770
AFFIDAVIT FOR ESTABLISHMENT OR REVIEW OF A CHILD SUPPORT ORDER
Respond to each question. If the question does not apply to you, write N/A (not applicable), or if you do not know the answer, write UNK
(unknown).
Please print or type legibly
A. Personal Data
Court / CSEA Case number _______________
Name _______________________________________________________________________
Address _____________________________________________________________________
Home Phone ________________________________
Work Phone _________________________________
Social Security Number ________________________
Date of Birth ____/____/____
Name of other party: ____________________________________________________________
Address & phone number of other party:_____________________________________________
Date of birth and/or social security number of other party: _______________________________
CHILDREN OF THIS ACTION:
NAMES:
___________________________
___________________________
___________________________
DATES OF BIRTH:
____/____/_______
____/____/_______
____/____/_______
Number of minor children of this action living in your home? ________
B. Other Support Obligations
1.
Do you have any other minor children (NOT including stepchildren) for whom you are required to pay support? If
so, please give their names and dates of birth:
_____________________________________________________________________________________________
_________________________________________________
If yes, how much do you pay a month? $_________
3.
Arrears amount? $____________
Do you pay spousal support to a former or current spouse? ______
How much do you pay? $________
4.
If you are paying child support and/or spousal support on another case, in what County and State was the order
issued and what is the court order number?
County: ___________
State: _____________
Order Number ___________
*If you have an order in another State, provide a copy of the order.
5.
Number of other minor children in your home that were born to you or adopted by you and not a party to this action
(DO NOT include step children) ______
Please provide their names and dates of birth:
_______________________________________________________________________
_______________________________________________________________________
6.
Do you receive support for these children? ______
Amount per month? $___________
C. Income
1.
Are you Self Employed? _____
* If you answered ‘yes’ to this question, you MUST provide your tax documents, including a 1099 or Schedule C, showing your
income and business expenses.
2.
Name of your present or most recent employer:_________________________________
3.
Address of present or most recent employer: ___________________________________
4.
Employer phone number: ____________________
5.
Dates of employment: ______________ to _______________
6.
How often are/were you paid?
[ ] weekly [ ] every other week [ ] twice a month [ ] monthly
[ ] other
If “other”, please explain: __________________________________________________
7.
What is/was your hourly wage? $_________
8.
Number of hours worked per week? ________
9.
Gross annual income from Employment / Self-Employment:
*Do not include overtime, bonuses, worker’s compensation, or unemployment.
Overtime rate? $_________
Two Years ago $_____________ Last Year $____________ This year $_____________
10.
Overtime and/or Bonuses:
Two Years ago $_____________ Last Year $____________ This year $_____________
11.
If you have been employed with present employer for less than one year, list previous employer and address:
_________________________________________________
12.
List hourly wage with previous employer: $________
13.
Other Income for current year:
Interest or Dividends:
$_____________
Unemployment Compensation
$_____________
Workers Compensation:
$_____________
Veteran’s Benefits:
$_____________
Other Pension:
$_____________
Alimony:
$_____________
Tips:
$_____________
Social Security:
$_____________
Other
$_____________ please specify below
_____________________________________________________________________________
_____________________________________________________________________________
*You must provide documentation of this income, such as approval letter for SSI or SSD, W-2 and tax forms and pay stubs.
14.
Do you receive public assistance? _________ In what County/ State? _______________
15.
Amount of local income tax paid last year? ___________, what City?________________
16.
Do you have any medical conditions or disabilities which prohibit you from working?_____
*If yes, what condition? __________________________________________
* Must provide medical documentation and an note from your physician which prohibits you from working.
D. Education / Training:
If a parent is voluntarily unemployed or underemployed, child support may be calculated based on a determination of potential income. It
is within the CSEA’s discretion to impute income on a case by case basis. If the agency should decide to impute income, a determination
will be made of your employment potential and probable earnings level.
1.
Name and Location of High School: __________________________________________
Highest grade completed __________
2.
Name and Location of College, Vocational, Technical, or Trade School:______________
________________________________________________________________________
3.
Specialized training or skills: ________________________________________________
________________________________________________________________________
4.
Degrees obtained: ________________________________________________________
E. Health Insurance:
1.
Do you provide health insurance for the child(ren) of this order? ____________
2.
If yes, what is the annual cost for Family coverage? $ ______
Annual cost of single coverage? ______
* must provide cost of both plans
3.
Is the insurance provided through you or your current spouse? _____________
4.
Name of your insurance company: _____________________________________
Address: _________________________________________________________
Plan or Group Number ______________________
5.
If the child(ren) is/are not currently covered by insurance, does you employer provide a health insurance plan?
_______
If yes, what is the annual cost for Family coverage? $ ______
Annual cost of single coverage? ______
Other:
1.
Do you provide childcare for the child(ren) of this action while you are at work,
training, or school? ____
If yes, how much do you pay? $________
*Provide proof of childcare expenses for credit.
2.
Do you pay mandatory work related expenses?
If ‘yes’, please list: __________________________________________________________
*Provide documentation of expenses
I swear or affirm that this information is complete and truthful to the best of my knowledge:
_____________________________
Signature
_____________________
Date
Sworn to before me and subscribed before me this _______day of ___________, 20__.
___________________________
Notary Public
THIS AFFIDAVIT MUST BE NOTARIZED
COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
Robert D. Rinfret
v./and
Respondent/Petitioner
Instructions: Check local court rules to determine when this form must be filed.
List ALL OF YOUR PROPERTY AND DEBTS, the property and debts of your spouse, and any joint property or debts. Do
not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your
best estimate, and put “EST.” If more space is needed, add additional pages.
AFFIDAVIT OF PROPERTY
Affidavit of
(Print Your Name)
I. REAL ESTATE INTERESTS
Present Fair
Market Value
Address
1.
$
2.
$
Mortgage
Balance
Titled To
Husband
Wife
Both
Husband
Wife
Both
Equity
(as of date)
$
$
$
$
TOTAL SECTION I: REAL ESTATE INTERESTS
$
II. OTHER ASSETS
Category
A. Vehicles and Other
Certificate of Title
Property
Description
(List who has possession)
(Include model and year of automobiles,
trucks, motorcycles, boats, motors, motor
homes, etc.)
1.
2.
3.
4.
5.
6.
B. Financial Accounts
1.
2.
3.
4.
Titled To
Value/Date of Value
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
(Include checking, savings, CDs, POD
accounts, money market accounts, etc.)
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Category
C. Pensions &
Retirement plans
Description
(List who has possession)
(Include profit-sharing, IRAs, 401k
plans, etc.; Describe each type of plan)
1.
2.
3.
4.
Titled To
Value/Date of Value
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
D. Publicly Held Stocks,
Bonds, Securities &
Mutual Funds
1.
2.
3.
4.
Category
E. Closely Held Stocks &
Other Business Interests
and Name of Company
Description
(List who has possession)
(Type of ownership and number)
Titled To
Value/Date of Value
1.
Husband
Wife
Both
$
2.
Husband
Wife
Both
$
F. Life Insurance Type
(Term/Whole Life)
(Any cash value or loans)
(Insured party
& value upon death)
1.
Husband
Wife
Both
$
2.
Husband
Wife
Both
$
3.
Husband
Wife
Both
$
4.
Husband
Wife
Both
$
Category
G. Furniture &
Appliances
1.
2.
3.
4.
Description
Who Has
Possession
Value/Date of Value
(Estimate value of those in your
possession, and value of those in your
spouse’s possession)
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
H. Safe Deposit Box
(Give location and describe contents)
1.
2.
I. Transfer of Assets
2.
3.
4.
J. All Other Assets Not
Listed Above
1.
2.
Husband
Wife
Both
$
Husband
Wife
Both
$
Explanation: List the name and address of any person (other than creditors listed on your
Affidavit) who has received money or property from you exceeding $300 in value in the past 12
months and the reason for each transfer.
1.
Category
Titled To
Description
(Also list who has possession)
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Husband
Wife
Both
$
Titled To
Value/Date of Value
Explanation: List any item you have not
listed above that is considered an asset.
Husband
Wife
Both
$
Husband
Wife
Both
$
TOTAL SECTION II: OTHER ASSETS
$
III. SEPARATE PROPERTY CLAIMS: Pre-marital assets, gifts to one spouse only, inheritances
If you are making any claims in any of the categories below, explain the nature and amount of your claim. This
includes, but is not limited to, inheritances, property owned before marriage, and any pre-marital
agreements.
Category
(Pre-marital Gift, Inheritance,
etc., acquired after separation)
Description
Why do you claim this
as a separate property?
Present Fair
Market Value
1.
$
2.
$
3.
$
4.
$
5.
$
TOTAL SECTION III: SEPARATE PROPERTY CLAIMS
$
IV. DEBT
List ALL OF YOUR DEBTS, the debts of your spouse, and any joint debts. Do not leave any category blank. For
each item, if none, put “NONE.” If you don’t know exact figures for any item, give your best estimate, and put
“EST.” If more space is needed to explain, please attach an additional page with the explanation and
identify which question you are answering.
Type
Name of
Creditor/Purpose
of Debt
Account Name
Name(s)
on Account
Total Debt
Due
Monthly
Payment
A. Secured Debt
(Mortgages, Car,
etc.)
1.
Husband
Wife
Joint
$
$
2.
Husband
Wife
Joint
$
$
3.
Husband
Wife
Joint
$
$
4.
Husband
Wife
Joint
$
$
5.
Husband
Wife
Joint
$
$
B. Unsecured
Debt, including
credit cards
1.
Husband
Wife
Joint
$
$
2.
Husband
Wife
Joint
$
$
3.
Husband
Wife
Joint
$
$
4.
Husband
Wife
Joint
$
$
5.
Husband
Wife
Joint
$
$
TOTAL SECTION IV: DEBT
$
V. BANKRUPTCY
Filed by: Wife,
Husband, Both
1.
2.
Date of Filing:
Case Number
Date of Discharge
or Relief from Stay
Type of Case
(Ch. 7, 11, 12, 13)
Husband
Wife
Both
Current Monthly
Payments
$
Husband
Wife
Both
$
TOTAL SECTION V: BANKRUPTCY
$
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
Notary Public
My Commission Expires:
,
.
COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
ROBERT D. RINFRET
v./and
Defendant/Petitioner
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
figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages.
AFFIDAVIT OF INCOME AND EXPENSES
Affidavit of
(Print Your Name)
Date of marriage
Date of separation
SECTION I - INCOME
Husband
Yes
Employed
Wife
No
Yes
No
Employer
Payroll address
Payroll city, state, zip
12
Scheduled paychecks per year
24
26
52
12
24
26
52
A. YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE
YEARS
Husband
Base yearly income
Yearly overtime, commissions
and/or bonuses
Wife
$
3 years ago
20
$
$
2 years ago
20
$
$
Last year
20
$
$
3 years ago
20
$
$
2 years ago
20
$
$
Last year
20
$
B.
COMPUTATION OF CURRENT INCOME
Husband
Wife
Base yearly income
$
$
Average yearly overtime,
commissions and/or bonuses
over last 3 years (from part A)
$
$
Unemployment compensation
$
$
$
$
$
$
$
$
$
$
Disability benefits
Workers’ Compensation
Social Security
Other:
Retirement benefits
Social Security
Other:
Spousal support received
Interest and dividend income
(source)
Other income (type and source)
$
$
TOTAL YEARLY INCOME
$
$
Supplemental Security Income
(SSI) or public assistance
$
$
Court-ordered child support that
you receive for minor and/or
dependent child(ren) not of the
marriage or relationship
$
$
SECTION II – CHILDREN AND HOUSEHOLD RESIDENTS
Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship:
Name
Date of birth
Living with
In addition to the above children there is/are in your household:
adult(s)
other minor and/or dependent child(ren).
SECTION III – EXPENSES
List monthly expenses below for your present household.
A.
MONTHLY HOUSING EXPENSES
Rent or first mortgage (including taxes and insurance)
$
Real estate taxes (if not included above)
$
Real estate/homeowner’s insurance (if not included above)
$
Second mortgage/equity line of credit
$
Utilities
o
Electric
$
o
Gas, fuel oil, propane
$
o
Water and sewer
$
o
Telephone
$
o
Trash collection
$
o
Cable/satellite television
$
Cleaning, maintenance, repair
$
Lawn service, snow removal
$
Other:
$
$
TOTAL MONTHLY :
$
B.
OTHER MONTHLY LIVING EXPENSES
Food
o
Groceries (including food, paper, cleaning products, toiletries, other)
$
o
Restaurant
$
Transportation
o
Vehicle loans, leases
$
o
Vehicle maintenance (oil, repair, license)
$
o
Gasoline
$
o
Parking, public transportation
$
o
Clothes (other than children’s)
$
o
Dry cleaning, laundry
$
Clothing
Personal grooming
o
Hair, nail care
$
o
Other
$
Cell phone
$
Internet (if not included elsewhere)
$
Other
$
TOTAL MONTHLY
C.
$
MONTHLY CHILD-RELATED EXPENSES
(for children of the marriage or relationship)
Work/education-related child care
$
Other child care
$
Unusual parenting time travel
$
Special and unusual needs of child(ren) (not included elsewhere)
$
Clothing
$
School supplies
$
Child(ren)’s allowances
$
Extracurricular activities, lessons
$
School lunches
$
Other
$
TOTAL MONTHLY
$
D.
INSURANCE PREMIUMS
Life
$
Auto
$
Health
$
Disability
$
Renters/personal property (if not included in part A above)
$
Other
$
TOTAL MONTHLY
E.
$
MONTHLY EDUCATION EXPENSES
Tuition
o
Self
$
o
Child(ren)
$
Books, fees, other
$
College loan repayment
$
Other
$
$
TOTAL MONTHLY:
F.
$
MONTHLY HEALTH CARE EXPENSES
(not covered by insurance)
Physicians
$
Dentists
$
Optometrists/opticians
$
Prescriptions
$
Other
$
$
TOTAL MONTHLY:
$
G.
MISCELLANEOUS MONTHLY EXPENSES
Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren)
$
Child support for children who were not born of this marriage or relationship and were
not adopted of this marriage
$
Spousal support paid to former spouse(s)
$
Subscriptions, books
$
Entertainment
$
Charitable contributions
$
Memberships (associations, clubs)
$
Travel, vacations
$
Pets
$
Gifts
$
Bankruptcy payments
$
Attorney fees
$
Required deductions from wages (excluding taxes, Social Security and Medicare)
(type)
$
Additional taxes paid (not deducted from wages) (type)
$
Other
$
$
TOTAL MONTHLY:
H.
$
MONTHLY INSTALLMENT PAYMENTS
(Do not repeat expenses already listed.)
Examples: car, credit card, rent-to-own, cash advance payments
To whom paid
Purpose
Balance due
Monthly payment
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL MONTHLY:
$
$
GRAND TOTAL MONTHLY EXPENSES (Sum of A through H):
$
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
Notary Public
My Commission Expires:
,
.
COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
ROBERT D. RINFRET
v./and
Defendant/Petitioner
Instructions: Check local court rules to determine when this form must be filed.
This 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
(Print Your Name)
Mother
Father
Are your child(ren) currently enrolled in
a low-income government-assisted
health care program (Healthy
Start/Medicaid)?
Yes
No
Yes
No
Are you enrolled in an individual (nongroup or COBRA) health insurance
plan?
Yes
No
Yes
No
Are you enrolled in a health insurance
plan through a group (employer or
other organization)?
Yes
No
Yes
No
If you are not enrolled, do you have
health insurance available through a
group (employer or other
organization)?
Yes
No
Yes
No
Does the available insurance cover
primary care services within 30 miles
of the child(ren)’s home?
Yes
No
Yes
No
Mother
Father
Under the available insurance, what
would be the annual premium for a
plan covering you and the child(ren) of
this relationship (not including a
spouse)?
$
$
Under the available insurance, what
would be the annual premium for a
plan covering you alone (not including
children or spouse)?
$
$
If you are enrolled in a health
insurance plan through a group
(employer or other organization) or
individual insurance plan, which of the
following people is/are covered:
Yourself?
Yes
No
Yes
No
Your spouse?
Yes
No
Yes
No
Minor child(ren) of this
relationship?
Yes
No
Yes
No
Number
Other individuals?
Yes
Number
No
Number
Yes
No
Number
Name of group (employer or
organization) that provides health
insurance
Address
Phone number
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
Notary Public
My Commission Expires:
,
.
SHARED PARENTING PLAN OUTLINE
The following outline is intended to assist in the preparation of a complete
shared parenting plan that conforms to the mandatory statutory provisions and the provisions required by the Holmes
County Domestic Relations Court. Optional provisions may be added.
All shared parenting plans must be attached to and accompanied by a petition for shared parenting signed by one parent
(in the event of a single plan) or both parents(if a joint plan). By statute, 30 days must expire between the filing of the
petition and plan and the granting of a final decree of shared parenting. This 30-day waiting period is consecutive with the
30-day waiting period from the filing of a petition for dissolution and the final hearing when shared parenting is part of a
dissolution. In post-decree matters, the follow-up 30-day hearing must be set before a judge. In the case of new, settled
divorce cases, the 30-day waiting period may be waived by a specific provision in the shared parenting plan decree so the
divorce decree and shared parenting decree can be filed simultaneously.
Below, are those provisions which need to be included in a shared parenting
plan.
1. DESIGNATION OF THE ELIGIBILITY FOR AID TO DEPENDENT
CHILDREN BENEFITS:
A child's primary residence must be designated (or the designation of one
parent as residential parent for the purpose of ADC eligibility) if one of the parties
is in receipt of ADC to assure the continued eligibility of these benefits.
2. PHYSICAL LIVING ARRANGEMENTS:
This section needs to describe the regular living schedule of the child in
each parent's home. It is important to keep in mind that a pattern which would be
appropriate for a preschool-age child may have to be altered once the child is
attending school, and to the extent that the parties are able to project into the
future and provide for a reasonable and practical plan for the child, this may be
an appropriate section to provide for such changes.
While it is not mandatory, the parties may wish to designate one party's
home as the "primary residence" and another party's home as the "secondary
residence". IT IS NOT APPROPRIATE TO DESIGNATE ONLY ONE OF THE
PARENTS AS THE "RESIDENTIAL PARENT" IN A SHARED PARENTING
PLAN. "Residential parent" means sole, legal custodian. In a shared parenting plan,
both parents are legal custodians of the children, and the use of the term "residential
parent" for one parent only is contradictory to the shared parenting concept.
It is also not appropriate to state that each parent is the residential parent and
legal custodian when the child/children are residing with that parent. ORC
3109.04(K)(6)
EXCEPTION: The statute does permit the designation of one parent as the residential parent for school purposes or as
residential parent for tax exemption purposes or as residential parent for purposes of ADC eligibility but those specific
designations do not effect the status of both parents as residential parents and legal custodians of the child(ren).
3. HOLIDAYS, VACATIONS, ETC.:
In spite of the fact that the living arrangements for the children may have been
fully described, a specific provision must be included in a shared parenting plan for sharing the major holidays, vacations,
birthdays, etc. This is also the appropriate section to include any provision for visitation with grandparents or other
relatives. The Standard Order of Parenting Time may be incorporated in part or in whole in the plan.
4. SCHOOL:
The statutory scheme mandates the designation of a school district. Our court
recognizes the difficulty in those cases where the children are not of school age and the living arrangements of the parties
at the time of a new decree may be somewhat temporary and subject to change. The provision should deal with the issue
of school placement to the extent that the parties can determine the most likely possibility at the time the matter is before
the court. An acceptable alternative is to designate the school district where either the mother or father resides.
“AGREEMENTS TO AGREE” WHEN THE CHILDREN REACH SCHOOL AGE ARE NOT ACCEPTABLE.
5. CHILD SUPPORT:
A Sole Residential/Shared Parenting child support computation sheet must be
prepared as part of a shared parenting plan. The required statutory computation
worksheet for shared parenting is the same worksheet that would be used in a sole custody situation.
THERE IS NO
SEPARATE LEGISLATIVELY APPROVED "SHARED PARENTING" COMPUTATION OR
FORMULA. In the event one parent is providing the "primary residence" for one child and the other parent is providing
"primary residence" for another child or children, you may wish to substitute a "Split Parental Rights" child support
computation sheet to arrive at a more equitable child support order.
Deviations from the guideline-suggested amount must be explained in financial
or monetary terms on line 27 of the computation sheet. Criteria for deviation from the guidelines are enumerated in R.C.
3119.22 and 3119.23 and in addition, there are some specific "extraordinary circumstances" applicable to shared
parenting orders which are enumerated in R.C. 3119.24(B)(1) through (4) and read as follows:
(i) The amount of time that the children spend with each
parent;
(ii) The ability of each parent to maintain adequate housing
for the children;
(iii) Each parent's expenses, including but not limited to
child care expenses, school tuition, medical expenses,
and dental expenses.
It is common to have deviations from the child support guidelines in shared parenting cases; however, it is by no
means considered automatic for neither party to pay support just because it is a "shared parenting." Where a disparity of
income exists and/or a disparity of physical care of the children exists, the exchange of child support is still considered
appropriate and equitable. For the most part, only cases where there is equal income and equal time spent in each
household will a lack of child support exchange be considered equitable, provided, there are adequate provisions for all of
the children's financial needs incorporated in the plan (See paragraph 6).
Child support must be stated in a monthly cycle only, stated per child, and
rounded off to the nearest dollar.
EMANCIPATION: Effective 1-1-98, the emancipation law in Ohio was revised as
follows: “...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...” All
child support orders must specifically address whether or not child support will continue after the child reaches age 19 and
is not yet graduated from high school.
6. OTHER CHILD-RELATED FINANCIAL MATTERS:
Where no child support is being exchanged or the child support to be exchanged
is significantly less than the guideline amount, a provision for an appropriate sharing of financial expenses of the child or
children, including but not limited to employment-related child care, clothing, school fees, camp or sports fees, lessons
and extracurricular activities, needs to be included.
7. PROVISION FOR CHILD/CHILDREN'S HEALTH CARE NEEDS:
A full Medical Support of Children provision must be included in every
shared parenting plan. The parties must complete the attached: (1) Private Heath Insurance Questionnaire; and (2) Health
Care Determinations form, both of which are available online. A reference to the Medical Support of Children Order, which
will be issued separately by the court, must be included as well as the attachment and incorporation by reference of the
Private Heath Insurance Questionnaire and the Health Care Determinations form.
8. TAX EXEMPTIONS:
Since both parties are custodial parents, the tax law is of little assistance for
determining who will be entitled to claim the children as dependents for tax purposes. That issue must be addressed in
the shared parenting plan. It is also appropriate to require the parent who will not be getting the tax exemption or will not
be getting it for a particular year to cooperate and execute any and all forms required by the Internal Revenue Service.
9. PARENTS' LIFE INSURANCE FOR BENEFIT OF CHILDREN:
The child/children or other parent needs to be made beneficiary of any existing
life insurance plan, especially one which is provided as an employment benefit, so long as the children remain
unemancipated.
10. OUT-OF-STATE RELOCATION:
The following language is required in all shared parenting plans:
Neither parent shall relocate the children out of state without first
obtaining a modified visitation order. The parties may submit an
agreed order modifying visitation, with a provision for allocation of
transportation expenses, to the court for adoption by the court as an order. If the parents are unable to
agree, the moving parent shall, prior to relocation, 1) file a motion asking the court to modify the visitation
schedule; 2) set a hearing; and 3) obtain a modified
visitation order. No continuances of the hearing will be granted
without written permission of the assigned judge or magistrate.
11. ACCESS TO CHILD'S/CHILDREN'S RECORDS:
The following language is required in all shared parenting plans:
Both parents shall have access to the same records, same school
activities and to any day-care center which the children attend on
the same basis that said records or access is legally permitted to a
custodial parent, unless a restrictive order has been obtained from
the court. It is the responsibility of the parent obtaining a restrictive
order to serve it on the appropriate organization.
12. NOTIFICATION OF CHANGE OF RESIDENCE OF EITHER PARENT:
The following language is required in all shared parenting plans:
Both parents shall give written notice to the other parent immediately upon any change of address and/or phone number
unless a restrictive order has been obtained from the court. A copy of the notice shall be provided to the Holmes County
Common Pleas Court, 1 East Jackson Street, Millersburg, Ohio 44654.
13. RELIGIOUS TRAINING:
Any agreement reached between the parents on religious training, if appropriate,
may be included in the shared parenting plan.
14. MISCELLANEOUS PROVISIONS:
The parents may wish to include provisions concerning cooperation, open
communication, encouragement of love and affection for the other parent, etc.
Post high school education costs may be addressed in the plan as well as any
other matter of importance to the parents.
15. MODIFICATION OF SHARED PARENTING PLAN:
A method for modification of the shared parenting plan may be included in
the plan. The most typical provisions are:
a. any modification shall be in writing, signed by both parties;
b. modification shall be in accordance with R.C. 3109.04(E)(2)(a) or (b);
c. parties shall engage in mediation to resolve any disputes that arise and shall
share costs of mediation equally before filing any motion in court to modify
this plan.
COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HOLMES COUNTY, OHIO
Case No.:
Plaintiff
JUDGE ROBERT D. RINFRET
-vs-
SHARED PARENTING PLAN
Defendant
:
This Shared Parenting Plan, by and between
hereinafter referred to as “Father”
hereinafter referred to as “Mother” is submitted by Mother and/or Father
and
pursuant to both parents’ Motion and/or request for Shared Parenting filed this same date. Both parents hereby
request the Court, pursuant to Ohio Revised Code section 3109.04 (D)(1)(a)(i, ii, or iii) to grant the parents the
shared parenting of their child(ren): (Include dates of birth)
.
Neither parent expects opposition to this plan from the other. Each parent is a caring and appropriate
parent with the ability to provide guidance, concern and a proper home environment for the minor children.
Neither parent has been convicted of or pleaded guilty to a violation of Ohio Revised Code section
2919.25 involving a family member, any other offense which resulted in physical harm to a family member, has
been determined to be the perpetrator of an abusive act that is the basis of an adjudication that a child is an
abused child or has acted or contributed in any manner resulting in a child being a neglected child.
The parties acknowledge that each has the present ability to cooperate and make decisions jointly with
respect to the minor children and the ability to encourage the sharing of love, affection and contact between the
minor children and each parent. The parents shall discuss and resolve all major issues jointly. The geographic
proximity of the parties to each other is not considered to be a barrier and makes the concept of shared parenting
a realistic alternative.
Both parents have read the “Shared Parenting Outline” that is one of the Holmes County forms available
online. The provisions of this Shared Parenting Plan are entered into with those principles in mind.
1. PHYSICAL LIVING ARRANGEMENTS
1.1
Mother and Father shall be the residential parents without regard to where the children are physically
located.
1.2
Mother shall have the following parenting time:
1.3
Father shall have the following parenting time:
1.4
Holidays with each parent shall be alternated. In the event the parents disagree as to holidays, they shall
adopt the Standard Parenting Order as it relates to holidays. The Standard Parenting Order is attached
hereto and incorporated herein.
1.5
Each parent shall have time with the minor children on the children’s birthdays (set forth with
specificity).
1.6
Each parent shall have two (2) weeks of uninterrupted annual vacation with the children with the other
parent to receive written notice of such vacation request at least thirty (30) days prior to the vacation
period’s commencement. However, reasonable telephone contact is to be allowed.
1.7
Mother and father shall have the minor children at any other time as agreed upon in advance between the
parents. The parents shall modify the schedule to meet the needs of the children. In the event they
disagree as to modification, they shall utilize mediation or counseling before filing motions with the
Court. Each parent will provide a bedroom(s) for the children separate from the parent’s room.
1.8
If either parent desires to relocate, the relocating parent, under this Shared Parenting Plan must notify
the Court of their intent to relocate and provide the Court with a new residence address promptly. Said
notice shall be filed with the Clerk of Courts Office and a copy forwarded to the other parent except as
provided in Ohio Revised Code section 3109.051(G)(2)(3) and (4). Upon receipt of the Notice, the Court
on its own motion or the motion of the non-relocating parent may schedule a hearing with notice to both
parents to determine whether it is in the best interest of the minor children to revise the Standard
Parenting Order for the minor children.
1.9
The current address for Mother is:
1.10
The current address for Father is:
2. CHILD SUPPORT , MEDICAL SUPPORT AND DEPENDENCY EXEMPTIONS
2.1
All matters relating to child support, medical support and dependency exemptions shall be according to
the attached separate document entitled “Judgment Entry Establishing Child Support and Medical
Support”.
3. CHANGE OF RESIDENCE OF MINOR CHILD
3.1
Neither parent may remove the child(ren) from Holmes County or its contiguous Ohio counties (i.e.
Ashland, Wayne, Coshocton, Knox, Tuscarawas counties) and establish residence for them in another
county without first obtaining a court order or an agreed entry permitting such removal. (Note: To have
legal effect, an agreed entry must be signed by both parents, their attorneys (if any), and the Court, and
thereafter be filed with the Holmes County Clerk of Courts.)
4. ACCESS TO ALL OTHER RECORDS AND ACTIVITIES
4.1
Both parents shall be entitled to any and all other records related to the child (ren).
4.2
Both parents shall be entitled to attend student activities relating to the child (ren).
4.3
Both parents shall have access to any day care center, day care provider or babysitter that is, or that in
the future may be, attended by the child(ren).
5. SCHOOLS
5.1
The parents shall consult as to the appropriate school placement for the minor child(ren). It is the
parents’ intent that the minor child(ren) attend public/private/parochial schools.
5.2
Both parents recognize that the child(ren) legally may attend either parent’s school system. Currently
residence shall be used for school registration purposes.
6. RELIGION
6.1
The parents shall consult as to the appropriate religious education and training for the minor child(ren).
It is the parents’ intention to raise the minor child(ren) in the
faith.
7. TRANSPORTATION
7.1
shall provide transportation at commencement of parenting time and shall
provide transportation at termination of said time.
7.2
Both parents acknowledge their responsibility to discuss activities important to the child(ren) in
advance, including times, dates and transportation needs, so that the child(ren) are not deprived of
activities and maintaining friendships. The parent who has the child(ren) will take the responsibility for
transportation, as agreed, to schedule activities and to school.
8. DISCIPLINE
8.1
The parents shall consult with each other regarding consistent and appropriate forms of discipline. The
parent with whom the child(ren) are in residence at that time shall make the day to day decisions
regarding discipline and shall advise the other parent immediately of his or her serious concerns about
the minor child(ren)’s behavior. The parents shall strive to maintain consistent methods of discipline in
the child(ren)’s best interest.
9. LIFE INSURANCE
9.1
Each parent shall name the minor child(ren) as equal beneficiaries on all existing or comparable life
insurance policies currently in effect through the parents’ employment. At the parents’ discretion, a term
policy in an equal face value amount may be substituted for the employment life insurance policy. Either
parent may name a trust and a trustee of his or her own choosing on behalf of the minor child(ren) as the
beneficiary of such policy proceeds informing the other parent in writing of such action.
10. MEDIATION
10.1
In an effort to implement the provisions of this order concerning shared parenting, father and mother
shall, in the event of any major disagreement between them relating to the minor child(ren) and prior to
any court hearing, seek co-parenting counseling, mediation and/or non-binding arbitration with qualified
individuals knowledgeable about the subject matter on which they disagree, in an effort to resolve all
disagreements that they themselves are unable to resolve. Parties choosing co-parenting counseling or
mediation shall attend at least three (3) sessions of either process unless the process is deemed
unproductive and terminated prior to the completion of three sessions by the counselor or mediator. The
parties shall equally share the cost of any process chosen, unless they agree otherwise, or unless the
Court orders costs allocated on some other basis. The parties may file the appropriate motions prior to
the completion of the process chosen. However, no hearing shall be held, except by order of the Court,
until the process is completed.
11. MISCELLANEOUS
11.1
Findings of Fact and Conclusions of Law pursuant to Ohio Revised Code (O.R.C.) section 3109.04,
3109.051 and 3109.052 are hereby waived, are not required, or have been addressed elsewhere by the
Court.
11.2
Any keeper of any record who knowingly fails to comply with this plan, or a division (H) of section
3109.051 of the Ohio Revised Code, and any school official or employee who knowingly fails to comply
with this order or division (J) of section 3109.051 of the Ohio Revised Code is in contempt of Court.
11.3
Willful non-compliance by a parent/party with this plan may result in a finding of contempt resulting in
thirty (30) days to ninety (90) days incarceration, a $250.00 to $1,000.0 fine, and an award of the
moving party’s attorney fees and costs.
11.4
By signature on this plan the parents knowingly and voluntarily waives any requirement that the Court
issue separate findings of fact/conclusions of law pursuant to Ohio Revised Code 3109.04, 3109.051 and
3109.052.
12. REPRESENTATION
12.1
Both parents have/have not at all times been represented by counsel.
12.2
Mother is represented by
, Esquire, Phone: (
)_____ _____
Father is represented by
, Esquire, Phone: (
)
_____
13. CONTINUING JURISDICTION
13.1
The Holmes County, Ohio, Court of Common Pleas shall retain jurisdiction to enforce and/or modify
any and all provisions of this Shared Parenting Plan in the best interest of the minor child(ren) as
provided by law.
14. ENTIRE PLAN
14.1
This Shared Parenting Plan contains the entire Shared Parenting Plan and orders of this Court, and there
are no representations, warranties, covenants, or undertakings other than those expressly set forth.
15. INCORPORATION INTO DECREE
15.1
This Shared Parenting Plan, as approved and adopted by the Court herein, shall be incorporated into a
Shared Parenting Decree and entered as said Order of the Court.
RESPECTFULLY SUBMITTED
MOTHER
FATHER
DATE
DATE
ATTORNEY FOR MOTHER
ATTORNEY FOR FATHER
PARENTING TIME/COMPANIONSHIP/VISITATION SCHEDULES
LOCAL RULE 25(A)
(F) Visitation.
(1) General Provisions.
Visitation is a time for children to do things with the parent they do not live with.
Activities the non-residential parent does with the children or skills taught to the children help the time
to be rewarding. Helping the children to find friends in the non-residential parent’s neighborhood also
helps to make it like home for them. Liberal visiting arrangements are encouraged, as contact with
both parents is important to children. Specific items in any journal entry of the Court take precedence
over this rule. Changes or modifications can be made by the Court if the need for such is shown.
(a) Unless otherwise agreed in writing between the parties and subject to further
order of this Court, subparagraphs (2) and (3) set forth the minimum amount of visitation between the
non-residential parent and the children.
(b) Visitation does not constitute the non-residential parent picking the children
up and leaving them with someone other than a relative, other than as required for employment.
(c) The residence of the children shall not be removed from the State of Ohio
without first obtaining a modified allocation of parental rights and responsibilities order from this
Court.
(d) All parties shall refrain from arguments or breaches of the peace in the
presence of the children and in carrying out the terms of this Rule or an order of the Court. Any
arguments or breaches of the peace shall bee treated as contempt of Court.
(e) The non-residential parent shall be responsible for transporting the children to and from
visitation.
(f) The children shall be permitted to speak on the telephone at least twice per week with the
non-residential parent.
(g) The children shall be permitted to send and receive at least three letters or cards per week
to or from the non-residential parent.
(2) Standard Visitation Guideline.
Pursuant to R.C. 3109.051(F)(2), the following minimum amount of visitation between the
non-residential parent and the children shall be:
(a) Alternate weekends from Friday to Sunday for forty-eight hour period
commencing on the first weekend after this Order is issued. In the event the parties are unable to
agree as to the starting and ending time of said period, the Court Orders that said visitation shall
commence on Friday at 6:00 p.m. and shall conclude on Sunday at 6:00 p.m.
(b) The non-residential parent shall have visitation one weeknight per week. If the
parties are unable to agree, then this midweek visitation shall be every Wednesday evening from 5:30
p.m. until 7:30 p.m. (during the school years) or 9:00 p.m. (during school vacation periods).
(c) The children and/or the residential parent have no duty to await the nonresidential visiting parent for more than thirty (30) minutes from the beginning of the visitation time.
The non-residential parent being late more than thirty (30) minutes shall operate as a forfeiture of that
visitation period.
(d) For the purposes of visitation, there are eight (8) holidays as follows:
1. New Year’s Eve
2. Martin Luther King Day
3. President’s Day
4. Easter
5. Memorial Day
6. Fourth of July
7. Labor Day
8. Thanksgiving
In the odd numbered years, the mother shall have the children on the odd number holidays;
the father shall have the children on the even numbered holidays. In the even numbered years, the
father shall have the children on the odd numbered holidays; and the mother shall have the children
on the even numbered holidays.
(e) Each year at Christmastime, the residential parent shall have the children on
Christmas Day and the non-residential parent shall have the children from 1:00 p.m. to 9:00 p.m. on
Christmas Eve. In addition, at Christmastime, the non-residential parent shall have the children for an
additional six (6) days visitation. Said visitation shall take place during the child(ren)’s Christmas
vacation from school, if applicable.
(f) On Mother’s Day and Father’s Day, no matter whose turn it is for visitation,
the children shall be with the respective parent for a period of at least eight (8) hours.
(g) The non-residential parent shall have a six (6) week visitation each summer, to
be arranged for as soon as vacation schedules are posted for both parties to have an opportunity to
take the children on vacation.
The six (6) week visitation period shall be arranged to allow a period of two (2) consecutive
weeks during the summer visitation for the residential parent to have the children. The residential
parent shall be permitted a minimum of alternate weekend visitation the same as provided in Section
1 above during the six (6) week visitation, if practicable.
(h) The children shall celebrate their birthdays in the home of the residential
parent; regardless of the non-residential parent’s visitation.
(3) Standard Visitation Guidelines for Long-Distance Travel.
Pursuant to R.C. 3109.051(F)(2) the following is the minimum amount of visitation
between the non-residential parent and the children when the parents live over 150 miles one way
apart from each other:
(a) Christmas: Christmas vacation, excluding Christmas Eve and Christmas Day, will be
divided in half and alternated annually, by half, between the parents. Additionally, Christmas Eve and
Christmas Day shall be alternated annually between the parents.
(b) Spring Break: School vacation (the Friday school is out to the day before school
recommences, to be coincidental with the days of the school vacation and not to interfere with school)
in odd numbered years or with the same alternation the Saturday before Easter to the Saturday after
Easter for preschoolers with no school-aged siblings.
(c) Alternative Holidays: For the purposes of visitation, there are eight holidays as follows:
1. New Year’s Eve
2. Martin Luther King Day
3. President’s Day
4. Easter
5. Memorial Day
6. Fourth of July
7. Labor Day
8. Thanksgiving
In the odd numbered years, the mother shall have the children on the odd numbered
holidays and vacations; father shall have the children on the even numbered holidays and vacations.
In the even numbered years the father shall have the children on the odd numbered holidays and
vacations; and the mother shall have the children on the even numbered holidays and vacations.
(d) Summer Vacation:One-half of the school summer vacation. Summer school necessary for
the children to pass to the next grade must be attended. The residential parent shall notify the nonresidential parent by March 15 of when the summer vacation begins and ends. The non-residential
parent must notify the residential parent as to his/her intentions by April 15.
(i) If the parties cannot agree which half of the summer they prefer, in the even numbered
years, the first half of the summer shall be spent with the non-residential parent, and in the odd
numbered years, the second half.
(ii) A general itinerary shall be provided either parent if more than two (2) days
will be spent away from either home when the children are in that parent’s care.
(e) Each parent may arrange an uninterrupted vacation of not more than two (2) weeks with
the children. A general itinerary of the vacation shall be provided for the other parent, including
dates, locations, addresses and telephone numbers.
(f) Additional Visitation: A once per month weekend visitation with the non-residential parent
will be permitted if the child’s traveling time does not exceed three hours one way. The residential
parent must be notified at least one week in advance. Weekend visitation shall be as defined in Local
R. 25(F)(2)(a) and (c).
(g) Father’s Day and Mother’s Day shall always be spent with the appropriate
parent.
SEPARATION AGREEMENT
This is an important legal document, and you may want to get the advice of an
attorney. Read this agreement carefully and completely before you sign it.
This AGREEMENT is made between ______________________________ (name) and
________________________________ (name), Husband and Wife, to determine all property
rights, including property and debt distribution, between them.
The parties to this Agreement represent the following:
1. They were married on _______________________ (date) in _______________________
(city and state).
2. Irreconcilable differences have arisen between the parties and (check one below)
_____ they are now living separate and apart, or
_____ they desire immediate separation and intend to separate.
3. There are no minor children of the marriage, either by birth or adoption, and the Wife is not pregnant.
4. The parties intend this agreement to be a full and complete settlement of their rights, one to another, as to the duty of
support to one another now or in the future, any rights of inheritance from one another, and any rights to any interest in or
to any property of the other, whether acquired before, during, or after marriage, or other rights or benefits that may arise
from the marital relationship.
The parties therefore agree as follows:
ARTICLE ONE: Separation
Each party shall hereafter live separate and apart from the other, and neither shall annoy, molest, interfere with or harass
the other in any way or manner, either directly or indirectly.
ARTICLE TWO: Spousal Support (each party must initial applicable provision).
_____
_____ Neither party shall pay to the other any amount, either in installments or in a lump-sum, for
spousal support. This provision may not be modified.
_____
_____ The ____ Husband or ____ Wife (check one) shall pay to the other party the sum of
$_____________ weekly or monthly (indicate which) in
spousal support. The terms of this obligation are (include for what
period; what events would terminate the obligation, e.g. remarriage,
cohabitation; whether the court can modify the amount or term):
ARTICLE THREE: Division of Property and Debts.
A. Real Estate (choose Option One or Two by both parties initialing)
Option One: _____ _____ The parties own no real estate to divide.
Option Two: _____ _____ The parties own real estate located at (address):
The parties agree as follows regarding the real estate (include whether to be sold or if one party will keep it; if to be sold,
how and what will happen to any proceeds; if one party is keeping it, whether refinancing is required; whether any
payment is due the other for the equity in the house; whether one party has to sign a deed over to the other):
B. Household Goods, Furnishings and Personal Property (choose Option One or Two by both parties
initialing)
Option One:
___
___
Each party shall keep any households goods, furnishings, and
personal property now in that party's possession, free of any claim
of the other.
Option Two:
___
___
Except as listed here, each party shall keep the household goods,
furnishings, and personal property in that party's possession. The
following items need to be delivered to the party not now in
possession (list items and who will deliver to whom and when the
delivery will occur):
C. Motor Vehicles (choose Option One or Two by both parties initialing)
Option One:
___
___
Each party shall retain title to and possession of all motor vehicles,
boats, campers and other titled or registered conveyances, now
titled or registered in that party's name. The party retaining the
vehicle shall be solely responsible for any debt on or expenses
regarding that vehicle and hold the other harmless from liability.
Option Two:
___
___
Except as listed here, each party shall retain title to and possession
of all motor vehicles and other forms of titled or registered
conveyance. The following agreement is made regarding the motor
vehicles (identify any vehicle that needs to be transferred to the
other party and who is responsible for any debt on the vehicle)
There is a joint debt on ___________________________________ (identify vehicle), i.e. both of us signed the note to
pay for the vehicle, and we agree that _____the Husband
_____the Wife (check one) will pay for that vehicle and
hold the other party harmless from liability.
D. Bank Accounts and Employee Benefits (choose Option One or Two by both parties
initialing)
Option One:
___
___
Each party shall retain any bank or investment accounts in that
party's name as well as any employee benefits, including pension,
retirement, stock ownership, 401(k) or other employer plans, free
and clear of any claim of the other. There are no joint accounts to be
closed and/or divided.
Option Two:
___
___
The parties agree to divide their bank accounts and employee
benefits as follows (include details of how the accounts, and which
accounts, will be divided):
E. Life Insurance Policies (choose Option One or Two by both parties initialing)
Option One:
___
___
Each party shall retain any life insurance policies owned by that
party, and the parties give up any interest in being named
beneficiary of the other's policies.
Option Two:
___
___
The parties agree as follows regarding their life insurance policies
(identify the policies to which the agreement applies):
F. Debts (choose Option One or Two by both parties initialing)
Option One:
___
___
Each party shall pay those debts in that party's name, and neither
party shall incur any debt in the name of or on the credit of the other
party. There are no joint debts.
Option Two:
___
___
The parties agree as follows regarding their debts (identify the debt,
the amount, and the party who will be paying that debt):
ARTICLE FOUR: Court Costs and Attorney Fees.
The court costs shall be paid from the deposit made with the Clerk of Courts, and any excess
shall be paid by ____ the Husband or ____ the Wife or ____ equally (check one) within sixty
(60) days of the final decree of dissolution or divorce.
Each party is responsible for any attorney fees incurred by that party, or the parties agree as
follows (if left blank, the parties pay their own fees) _________________________________.
ARTICLE FIVE: Complete Settlement.
This Agreement is a full and complete settlement of all spousal support rights and property
rights between the parties, each of whom does, by the provisions of this Agreement, release,
satisfy, and discharge all claims and demands against the other, including rights of dower,
Page 6 of 8 Separation Agreement
inheritance, descent and distribution, allowance for year's support, exemption from
administration, all rights as surviving spouse, heir, legatee, and next of kin, in the estate of the
other, and all rights to administer the estate of the other, and in all property rights that each now
has, or may acquire in the future, except as specifically agreed in this Separation Agreement.
This Agreement shall be binding on the parties' heirs, administrators, executors and assigns.
Please both initial to indicate your acceptance of this Article: _____
_____
ARTICLE SIX: Incorporation Into Decree.
It is agreed and understood that this Agreement shall not constitute consent by either party to a
divorce or dissolution of marriage; however, in the event that either party files a divorce action
or a dissolution proceeding is begun, the parties agree that this entire Agreement shall be
disclosed and presented to the Court in that proceeding or in any such proceeding now pending,
with the request that it be determined to be fair, just and proper, and that this Agreement and all
its terms and provisions be adopted by that Court and made a part of the Order of the Court in its final decree of divorce or
dissolution.
Please both initial to indicate your acceptance of this Article: _____
_____
ARTICLE SEVEN: Implementation of Agreement.
Except as otherwise provided in this Agreement, each party shall, upon the signing of this Agreement, deliver to the other
party, or permit the other party to take possession of, all items of property to which each is entitled. Within fourteen (14)
days after the journalization or filing of a decree of dissolution or divorce that incorporates this Agreement, whether
modified or amended, each party shall execute or sign and shall deliver any and all deed, titles, certificates, or other
documents necessary to carry out the terms of this Agreement. Upon the failure of either party to deliver any document,
this Agreement shall constitute and operate as the properly executed document, and the County Auditor, County Recorder,
and Clerk of Courts, and any other public and private officials are hereby authorized and directed to accept this
Agreement, or a properly certified copy of it, in lieu of the document regularly required for such conveyance or transfer.
Please both initial to indicate your acceptance of this Article: _____
_____
ARTICLE EIGHT: Full Knowledge and Disclosure.
Each party acknowledges that he or she has read all the terms and conditions of this Agreement
and understands all the terms. Each party further represents that he or she has made a full and disclosure of assets and
liabilities, earnings and benefits, so that the other party could take that into account in negotiating this Agreement. Each
party further represents that he or she is satisfied with the disclosure made by the other party.
Please both initial to indicate your acceptance of this Article: _____
_____
ARTICLE NINE: Modification of Agreement.
This Agreement may only be modified in writing, and any modification must be signed by both
parties. No waiver or breach of any one term shall be considered a waiver of any other duty or
right under this Agreement, including any subsequent breach or default of a similar nature.
Please both initial to indicate your acceptance of this Article: _____
_____
IN WITNESS WHEREOF, the parties have signed this Agreement before the witnesses and on
the date set forth below:
Signed in the presence of:
Signature of witness to Husband
Signature of Husband
Signature of witness to Husband
Printed Name of Husband
Date Signed
Signature of witness to Wife
Signature of Wife
Signature of witness to Wife
Printed Name of Wife
Date Signed
INSTRUCTIONS FOR SERVICE
The Court cannot consider something unless it has been "served" on the other parties to
your case. If you are trying to enforce or change an order after your divorce, dissolution
or legal separation is over, the motion you file must be 'served' by the Clerk of Courts
(not by you) by certified mail. You must instruct the Clerk to do this, using the form
on the next page. It is titled "Instructions for Service."
Sometimes, someone will either refuse the certified mail or never claim it. If the mail is
returned to the Clerk from the Postal Service for either of these reasons, that information
is added to the "docket" in your case. Only then can you instruct the Clerk to send
service by ordinary mail.
There are certain exceptions to these service rules, especially when your case is already
underway. As an example, if your divorce is not final yet and all the original papers were
'served' properly, you will be able to serve things you file by regular mail. Or if your post
decree motions are already properly served and you are seeking a continuance, you can
serve that motion by regular mail. This website does not explain all the exceptions or
other legal methods of service.
IN THE COURT OF COMMON PLEAS
HOLMES COUNTY OHIO
DOMESTIC RELATIONS DIVISION
INSTRUCTIONS FOR SERVICE
Plaintiff
Case No.
Vs.
Judge
ROBERT D. RINFRET
Defendant
Date
Address
CERTIFIED MAIL
PERSONAL SERVICE
NUMBER OF SERVICE ATTEMPTS
RESIDENCE SERVICE
SHOW ADDRESS FOR SERVICE IF
DIFFERENT FROM ONE SHOWN IN CAPTION
ADDITIONAL INSTRUCTIONS:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________
Signature of Plaintiff or Plaintiff’s Attorney
CLERK’S CERTIFICATE OF MAILING
Service of Process was sent by ordinary mail this _________ day of _____________________, ____________.
Attest: Clerk of Courts _______________________________
_______________________________________
Deputy Clerk
Note: You can only check ordinary mail after certified mail was requested and the party
to be served either failed to pick up the certified mail or refused the certified mail.
IN THE COURT OF COMMON PLEAS
HOLMES COUNTY, OHIO
____________________________
____________________________
____________________________
CASE NUMBER ____________________
VS
____________________________
____________________________
____________________________
MOTION FOR _____________________
___________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________
PROOF OF SERVICE
I hereby certify that an exact copy was sent to _____________________________________
by regular U.S. Mail on this _______ day of _______________, 20_____.
__________________________________