.

'
COURT OF COl\Ii\ION PLEAS
DIVISION OF DOMI':STIC RELATIONS
HAMn,TON COUNTY, OHIO
MELISSA HENDON DETERS
Plaintiff

DR1302234

Date:

Case i'/o.
File No.
CSEA No.

Address: 11976 Stonernark Lane

Loveland, 011 45140

Judge

AFFlDAVIT OF Ii'/COME, EXPENSES

A,"D FINA.l'\'CIAL IJISCLOSURE

VS.

JOSEPH THEODORE DETERS

Defendant

Address: 15 W Fourth Street #503

Cincinnati, OH 45202
STATE OF OHIO, SS:
Now comes Melis!'a Hendon Deters, affiant herein, and having been duly cautioned and sworn, states that she has
been advised that this affidavit may be used for any or all of the following purposes: (I) to make complete disclosure of
affiant's income, liabilities and expenses; (2) to assist in determining orders of child support or spousal support when
applicable or any changes thereto; and (3) to provide for the issuance of the appropriate deduction order for support.
Minor and/or Dependent Children of this Marriage:
~P-".a-"-tn.:..::c::.:k,-,,J,,-.
""D""e""te"",rs",-,
...,tv"-'ra"-'ry~E""I~yse""'_'D=et""e_'_'rs'__
=.:Jo~nC!!a!!.th!..!!a~n_'_'..!...r'_'.
D~et""e_'_'rs'__
",Jo",:;""c""p-,-,-h-,,S,,-.
-"D:..>e"-'te"-'.f-"-s

age 9
age 20
age 23
age ::.24-'--

is residing
is residing
is residing
is residing

with ..:...1
with..:...1
with
with

_
_
_

GROSS YEARLY INCOME

SECTrON r
Husband
$87.828.00
$0.00

(1)1 Yes_ No
Employed?
.......... Estimate
Base yearly wages
......................... Yearly Averages, Overtime, Commission

Hamilton County Prosecutor

23Q E. 9th Street Suite

$202,800
$290.628.00

DR 7.3 (Revised 07/01/2001)

Ycs_ No (2)
Estimare
& Bonus Income

Employer
Payroll Address
City, State, Zip
Scheduled Paychecks Per Year
Unemployment Benefits
Workers' Compensation
Social Security or Other Disability Benefits
List Source in Section D-2
Spousal Support Received
Interest/Dividend Income
List Source in Section 0-2
Public Assistance or
Income Supplement Security
Other Income Received
list Source in Section IIl-B
TOTAL YEARLY INCOME

Wife
$50.000.00
""$O"-'.-".OO~

Public Librnry of Cincinnati and

Hamilton County Foundation

800 Vine Street
Cincinnati. Ohio 45202
.........................

12

$0.00
$0.00
$0.00
$0.00
$0.00
SO.OO
$0.00
$50.000.00

"

Husband (I)

Wife (2)
ANNUAL

INCOME,

Base Income

Overtime.
and/or
Bonuses

2010 year 3 ... "'-$0"-'.""'00"---__

20 I I year 2 . ""$0"".""00"----__
2012 year I ... =$0=.0""'0'--- __

""$0"-'-.0"-'0"--__
""$0""'-.0""'0"-__
$0.00

SO.OO
SO

per year
per year

per year

$0.00

per year

per year

SECTION

II

OVERTIME
AND BONUSES
(Past Three Years)

Base Income

2010
20 II

year 3
year 2
year I

Overtime,
and/or
Bonuses

=$O~.O=O
_
=SO"-,.",,oO~ __
""$0=.0""'0'---__

$0.00
$0.00
$0.00

MOST RECENT
2012
YEAR
"D.JUST;\,I ENTS
.............. Court Ordered Support Paid for other child(ren)
. $0.00
........ Court ordered Spousal Support Paid to a Fonner Spouse
. $0.00
..... Number of Other Dependant Children living with the Party
.
(Excluding Unadopted Step Children)
......... Child Support Received for Other Dependent Children
""$
Indicated Immediately Above
... Health Insurance Premium Paid by Party ifChildrcn Included .. $0.00
For Post Decree Modifications Only
Gross Income of Current Spouse or
$
............. Other Contributor in Household
.

AFFIANT'S MONTHLY

per year
per year

--'p""e::..r..r.V"'C<lO!.r
per ycar
per year

EXl)ENSES

List expenses below for your present household. There are .L adults and
A. Housing
l . Rent or Mortgage (including taxes & insurance)
2. Utilities
a. Gas & Electric
b. Water & Sewer
c. Telephone (excluding long distance)
d. Trash Collection
e. Cable Television
3. Other: Security System
Homeowner A$sociation Fees
TOTAL HOUSISC
,
,
,
13.Other
I. Car Repairs & License
2. Insurance: Car
3. Medical Expenses (not covered by insurance
4. Clothing
5. Grocery Items (to include food, laundry & cleaning products/toiletries,
etc.)
6. Child Related Expenses
a. (employment related only)
b. Other:
7. Gasoline & Oil
8. Other: Car PaYment for Joe and Jonathan
l\10NTHL Y TOT AL .............
, .. ,...............................................

DR 7.3 (Revised 0710112001)

EARI~ED

I.

children in my household.

$3,127.37
=$"'-27'-'8=.5"-'7'---~$.i;!o83""..!.18~

_
_

"'-$:::..3....,10::..:..0"'0"-"'-$"'-0

_
_

""$2"'6"'0::..:..9""5"--

""$..:..;18::..:.."'00"'--

""S6""0"".0"'0"'--

""S4"-'.
....
13""'8""'.0.!....7

",S,,-9
0"".-"-0"'-0
2=.;5~
=.S=.2"'-'l5'-'..0"'0"--

_
_
_

::::S..!,47.!..!8:..:..

"'-S-'-'I.""50"""'0~.OO=-

"'"S-'-'1..=.2"'-00~.""'0"'-0

""$4~8"-'2.,;.0~8"-""SO""'-.",-,OO~
"'$.:..72""0""."'00"-

_
_
_

"'$'"'-tl9"-'S""'.- .4"-8"--

""$5"->.,3=8=3~.8;..:..1

PI!.2

C. MONTHLY
INSTALLMENT
(Do not list expenses previously
TO WHOM PAID

PAYMENTS
listed in Section B)
PURPOSE

Fifth Third Master Card

Fifth Third Master Card
Visa
AAA- Bank of America
Bank of America Visa
Macy's American Express
GE Credit Union
VWCredit
MONTHLY
TOTAL

Credit
Credit
Credit
Credit
Credit
Credit
Buick
Passat

Card
Card
Card
Card
Card
Card
Loan
Loan

7,855.36

MONTHLY
PAYMENT
$500.00
$500.00

14,195.19
9.500.00

S500.00

34,000.00

$1,000.00

BALANCE

DUE

11,403.79

$500.00

$125.00
$41\3.00
$155.37
$3,763.37

$18,486.75
GRANO

TOTAL

MONTHLY

EXPENSES

(Sum A, B, C, plus D (optional)

SECTION
III
FINANCIAL
DISCLOSURE
A. list all funds on deposit in any and all accounts in any bank, savings & loan, credit union, regulated investment
company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of
deposit ("CD"), investment, savings, individual retirement ("IRA"), stock option, etc. Attach additional pages if
needed.
Account No.
Name(s) on Accounts
Balance Date of
Name and Address of
this Affidavit
Financial Institution
xxx586
Joseph Deters
S;
Fifth Third Bank

Filth Third Bank

xxx500

Joseph and Melissa

Deters

Huntington

Bank

xxx400

Joseph and Melissa

Deters

Huntington

Bank

xxx06n

Melissa Deters

Melissa Deters

Fifth Third Bank

Huntington

Bank

xxx760

Melissa Deters

B. Other income sources listed in Section I (i.c., retirement/pension

benefits, disability income, interests or dividend
income, rentals, annuities, etc., not listed in Section III-A). Attach additional pages if needed. Need not complete prcdecree.
Name & Address of Source

Income or Benefits
Per Month

NONE

DR 7.3 (Revised

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

0710112001)

per

;;

SECTION

OTHER

IV

ASSETS

1. Describe assets of more than $1,000 in value not otherwise

AND LUMP SUM TNCOME

listed in this affidavit (equity in real estate, stocks,

bonds, other investments, etc.), Attach additional pages if needed.

NONE

Value
S

2. List any lump sum income (bonus, gifts, inheritance, etc.) in excess of $500, expected to be received within the next
six months, not otherwise listed in this affidavit. Attach additional pages if needed.
Source NONE
Value "'$
_
Addrcss
_
Affiant states that the information

contained

herein is complete and accurate to the best of his/her information,

knowledge or belief under penalty of law.

Attorney for Plaintiff

Atfi nt:

______

iAMgd H, MO~KOWnt.

Att5I'il8i d UJ11I

PUBliC. !!'TATS 01' oJffO

My Cornrnlsalon has no explrctUOlT
dote. 64!CUoo 147.03 OACt

,,"aTARY

DR 7J (Revised 07/01(2001)

, 2o~3

'I

D. OPTIONAL
(Additional Monthly Expenses)
Complete if an award of spousal support is at issue or in the event that you are seeking a significant deviation from the
child support schedule.

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

""$""0.""0""0

2.

,""$0"'.""0"'-0

"",,
Extraordinary Visitation-Related Travel Expenses
3. Extraordinary Obligations to other children, minor and handicapped,
4. Mandatory Deduction from Wages (Not taxes, Social Security
5. Hair Care, Dry Cleaning
6. Newspapers, Periodicals, and Books
7. Child Care (not employment
related)
,
" .. "
8. Children'S School Lunch Program
9. Children's Allowances, Activities
10. Tuition (lor Minor Children or Sell)
II. Entertainment
12. Contributions
13. Additional Taxes Paid (not from wages
14. Memberships (Associations, Clubs)
15. Travel, Vacations
16. Water Softener
17. Housing Repairs
18. Housekeeping Services
19. Lawn Service
20. Other (Specify)
School supplies

Gift,
Sorority
Pets
Mary Elyse Deter Rent
Cable for Boys
TOTAL OTHER

DR 7.3 (Revised 07/011200 I)

not step-children

_
_

.$""0"".""00"'--

.$""O~.""OO"'--

.$""2::...4!.-"2"--'.5'--':0~

""$0"".""00"'-

"'$-"0'-".0...,0'--

.$""..:...10"".""00"-

"

.,,$-'--70"--'0"'-.0""0"--

"'S""1.L.!.4"'66""'.:<,0"'0

.$"'-4-'-'5:<.!0'-'-.0"'-'0~

""$...,10...,0'-".0""0'--

""$0"'.:.=,0""0

.$-:<.""78~.-"-00"-.$=2=0"-'0'-'-.0""0"--

""$0"".""00"'--

""$....,10..,0""'.0""0"-""'$.:..;10""0""'.0""0'-.$"'-'-'IR.:..,:4"".0""'0'--

_
_

(D)

%-,$-'-'15"".0=-0"-.$""2""'5""'0"".0-"--0

""'-$4.!-'' ' 6' ' '.0'' ' 0' --

$25.00
$685.00
""$-'--"8..,0"".0""'0'-EXPENSES

$5.201.50

1\!.5

,I

~.,

COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
MELISSA
Plaintiff

HENDON

Date:

DETERS

Case No.

DR13

a2234

vs.
File No.
JOSEPH THlWDORE
Defendant

DETERS
CSEA No.

Judge

AFFIDAVIT

fN COMPLIANCE WITH
REVISED CODE

Q127.23 OF THE mllo

Melissa Hendon Deters discloses the following information under oath and represents that it is true to the best
of Wife knowledge and belief based upon what is reasonably ascertainable:

I.[ 1 [ am requesting the court to not disclose my address or that of the child named below. I am claiming tiH1I
my address is confidential pursuant [Q Ohio Revised Code 3127 .23(D) and should be placed under seal in that the health,
safety, or liberty of myself and/or the child would be jeopardized by the disclosure of the identifying information. I
understand that a hearing will be held to determine whether the information can be disclosed based on my claim.
2. The name(s) and the present addressees), or the whereabouts,
DOB 5/8/04

01. Patrick J. Deters

3. The child have lived at the following addresstes)

8256 Cherry laurel Court Liberty Township.

4. The name(s) and present address/es)

<1.

u C')
~u-\...'

('oJ

7!.

lWve

participated,

~\.J'J

~u

during the last 5 years:

of all persons with whom the child have lived during the past 5 years are:
Address] es)
11976 Stonemark Lane Loveland, Ohio 45140
15 W. FourthStreet #503, Cincinnati, Ohio 452Q2
3737 Hazel Avenue Cins;innati, Ohio 45212

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

0, . Case Num~

0~
d. ex.

Present address: 1 1976 Stonemark

Lane Loveland. Ohio 45140

c:;.
5. I have not participated as a party, a witness, or in any way in some court action in this or another state
cercemint:i
custody, support, care of or visitation or parenting time with these same child.

1j3~

~o:?

child involved lire:

Prior Address( es)

Ohio45044

Names
Melissa Deters and Marv Elyse Deters
J oseoh Deters
Jonathan T. Deters and Joseph S. Deters

~ ~ ~

ofthe

~ U-!..:N""o.!!:~~
~

DR 2.1 (May 2006)

Name of Court
_

Kind orCase

6. I do not know of any proceedings that could affect this proceeding. including proceedings lor
enforcement 0 f chi ld custody determinations, relating to domestic violence or protection orders, to adjudicate the
child as an abused, neglected, or dependent child, seeking termination of parental rights, or adoptions. If I do know,
T have listed the information here:
_

7. The following persorus) are not parties to this case and (a) have physical custody of the child or (b) claim
to be a parent of the child or (c) claim to have custody, visitation or parenting time rights regarding the child. (If
None, write "None" on a line below)

State reason: A. B, or C from above

Name
None

8. By signing below, I understand that I have a duty to inform the court if I get any information about any
parenting proceeding or court case filed in another court about this same child that may affect this proceeding.

Sworn to before me and subscribed

in my presence this ~

day of IV.::>""~;Y"\

James H. Moskowitz 0064190

Attorney for Melissa Hendon Deters

DR 2.1 (May 2006)

'Ee (,"20~.

DIVISION OF DOMESTIC RELATIONS

COURT OF COlVUvlON PLEAS

0 R 1 3 0 2 '2 3 4

HAMILTON COUNTY, OHIO

I\lcll~'Il1 Hendon

Case No.

Deters

Plalntitf

File No.

CSE,' 1'.'0.

.JlId~e

Joseph Theedore Deters

Defendllnt

GHOUP

.
_y<:s

...x no

__ yes

.x no

* . * ....

..

IIE,\LTH
*" .

INSlmANCE
,'FrIOA
*****.**.*;fr

PL\l1\TIFF

"IT

**

DEFE:"DANT
Available

through

Other

employment

group

_ yes -X no
'.Iumana

"'AME

I~SURER'S

_no

~yc"S

plan

--r"I

t.QJl~~
'

ADDRESS

~.
'-'

'AM\!

,",'UMBER

I\lonthly

premium

Monthly
(Indicate

of lndividuul

premium

of Family

"0" if available

AI

r-

7047S6

Plan (employee

share)

Plnn (employee

N
N~""

rn

l>

-..g

COVERACES
Summarize

health cure benefits,

i.e .. major medical only. deductible,

;A~

-"-0

~ ~

health maintenance

organization,

etc. Anach $L'ParJt~cet

(f);:U

ere

necessary.

[ J No

( J Yes
J Self

[ J Dependent
[ J Yes

children

[ J Y..-:;

ofthe

Is coverage

J Above named spouse

presently

in effect?

Who is covered?

[XjYL'S

) No

[X)

J Above named spouse

[X )

marriage

Self

DC-Pl'l1dl'l11

children

of the marriage

[ )1\'0

Is u pnrtlcipanr

card nvnilabtc?

[X J Yes

J No

[ ) No

Is a prescription

card uvuiluhlc?

[X j Yes

INo

li:mploycr's

Ins. Ccordlnatnr's

Name and Telephone

The cost 10 purchase

4~~~

Numh('J"

COIlR,\

Joseph

MelisSa Hendon Deters

PbintiO-

COHm!!" will be

'I1H,XX]O/'l:

Deters

Defendant

State of Ohio. County of Hamilton:

Sworn

[0

before me and subscribed in

DR 7.16 (Oct. 1999)

Illy

presence hy Plaintitfthis

.!.JI.. day Of-'N~.l..O"--"0::..=e'-'-'iV'\'__'_'b:::...:e.::::..:r'__ __

20J.3....

"-,

~~(T1

co-puymcrus,

<

'3 n:z:

1--

share)

no cOSI 10 party)

;~--I
., pI::O

__ I_:u:'~

-<

Lcxingt{1O.Ky40512-POLIC\'

~.J

Hamilton COUNTY DOMESTIC RELATIONS COURT

CHILD SUPPORT COMPUTATION WORKSHEET
SOLE RESIDENTIAL PARENT OR SHARED PARENTING ORDER

DR624
EFF.10/08

Name of parties

Husband

and

Wife

Order No.

Case No.
1

Number of minor children

t8J

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

mother

father

shared

Column I

Column II

Column III

Father

Mother

Combined

INCOME:
1.

a. Annual gross income from employment or, when determined

appropriate by the court or agency, average annual gross
income from employment over a reasonable period of years
(Exclude overtime, bonuses, self-employment

income,

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

281,220

49.992

b. Amount of overtime, bonuses, and commissions

(year 1 representing

the most recent year)

Father

Mother

Yr. 3 (Three years ago) . . . . $

Yr. 2 (Two years ago) ......

Yr. 1 (Last calendar year) ...

$
$

$
$

AVERAGE

.............

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

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

that the lotal earnings from overtime and/or bonuses

during the current calendar year will meet or exceed the amount
that is the lower of the average of the three years or the year 1
amount. If. however, there exists

reasonable

the total earnings from overtime/bonuses

expectation

that

during the current

calendar year will be less than the lower of the average of the 3
years or the year 1 emount, include only the amount reasonably
$

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

b. Ordinary and necessary busmess expenses

_ .............

..............

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

2.

For self-employment

income:
...................

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

between the actual rate paid by the self-employed

individual

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

d. Adjusted gross income from self-employment
(Subtract the sum of 2b and 2c from 2a) ......................
3.

Annual income from interest and dividends

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

4.

Annual income from unemployment

compensation

Ol624 Effect;", 101(18

MoskowItz & Moskcwltz, tLC Prepared by James H. MoskowItz. E!q. James Moskowitz

(e) Family Law Software. Inc. v 15.03 11120t2QIJ ,:03pm

HUSband'&

Wile

Pogo 1

Order No.

Case No.

5.

Annual income from workers' compensation,

Column II

Column III

Father

Mother

Combined

disability insurance

benefits, or Social Security Disability/Retirement

6.

Column I

benefits

Other annual income (identify)

, .,

$._~ __

..:.O

....::.0

$__

..:.0
..:..:1
B:..:0:..c,D:..:D:..::.D

Mother:
Alimony from this relationship
7.

180,000

a. Total annual gross income (Add lines 18, 1b, 2d, and 3-6)
b. Health insurance maximum (Multiply line 78 by 5%), ,

ADJUSTMENTS
Adjustment

B.

281 ,220

14,061

$_----=2.::..29:.,:, 9:..:9:...::c2
$

1:...:12.:.5:.::..::.

TO INCOME:
for minor children bom to or adopted by either

parent and another parent who are living with this parent;
adjustment does not apply to stepchildren

(number of

children limes federal income tax exemption less child

support received, not to exceed the federal tax exemption)

9.

Annual court-ordered

support paid for other children

10,

Annual court-ordered

spousal support paid to any spouse or

former spouse.

, . , , , ...

,$

" , , , , , .. , ,,$

....::.0

..:.0

-..:.0

-..:.0

--=.O

180,000

, . , . . ..

5,906

, , , , . . . . . . . . . . . . . . . . . . . . . . . ..

(Add lines 8 through 12) . . . . . . . ..

185,906

$ __

$__

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

228,942

4::.,7:..:6:..::6 $

11,447

, . , ....

, , , , . , , , , . , . , .. , , . , , , ...

Amount of local income taxes actually paid or estimated to

11.

be paid , ,

, ,,

, .. ,

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

Mandatory work-related deductions such as union dues,

12.

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

retirement)

.....

, , . , . , ...

Total gross income adjustments

13.

14. a. Adjusted annual gross income (Subtract line 13 from line 7a)

....::.0

..::.0

...:1c..:,O:.:5~0

b. Cash medical support maxJmum (If the amount on line 7a, Col. I,
is under 150% of the federal poverty level for an individual,
enter SO on line 14b, Col. I. If the amount on line 7a, Col. I,
is 150% or higher of the federal poverty level for an individual,
multiply the amount on line 14a. Col. I, by 5% and enter this
amount on line 14b, Col. I. If the amount on line 7a, Col. II,
is under 150% of the federal poverty level for an individual,
enter SO on line 14b, Col. II. If the amount on line 7a, Col. If,
is 150% or higher of the federal poverty level for an individual,
multiply the amount on /ine 14a, Col. II, by 5% and enter this
amount on line 14b. Col. If.)

15.

, .. $.~ __

Combined annual income that is basis for child support order

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

,,

, ...............

, ,

$ __

3_24..:..,2_5_6

0(.624 EffecUve 10108

r.10SkOWitz&

MO$!o.owitz.I,..I.C

Prepared

by James H,

Moskowitz.

Esq. James

Moskowitz

(c) Family LU't'VSoftware.

Inc. v

15.03

1112OO01J

1:03pm

HUSband &

Wile

Pao2

.'

Order No.

Case No.

16.

Percentage of parent's income to total income

a. Father (Divide line 14a. Col. I. byline 15. Col. III). . . . .. .

Column I

Column II

Column III

Father

Mother

Combined

. .. .

29.39

70.61

b. Mother (Divide line 14a. Col. 1/. by line 15, Col. 11/)...........................

17.

a. Basic combined child support obligation (Refer to schedule, first

column. locate the amount nearest to the amount

on

line 15.

Col. III. then refer to column for number of children in this

family. If the income of the parents is more than one sum but
less than another. you may cetcutete the difference.)

$_~_1_5,-,,-,2_1_8

b. Income above top guideline bracket.

C. Percenttobeusooonincomeover$150.000.........

18.

17 4.256
10.1453

d. Support on Income over $150.000 (b c)

o. Total child support obligation (a + d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

$~ __ 3_2..:..,8_9_7

Annual support obligation per parent

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

9,668

b. Mother (Multiply line 17c, Col. III, by line 16b)

19.

1_7.:..,6_7_9

$~ __ 2-,3-,-.2_2_9

Annual child care expenses for children who are the subject
of this order that are work-, employment training-. or
education-related.

as approved by the court or agency

(Deduct tax credit from annual cost, whether

or not

$_~~

__

claimed)

a. Less: Federal child care tax credit ..........................

0_

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

c. Net child care costs

-'-0

20. a. Marginal, out-of-pocket

costs. necessary to provide for health

insurance for the children who are the subject of this order
(Contributing

cost of private family health insuranco,

minus the contributing

cost of private single neettn

insurance. divided by /he total number of dependents

covered by the plan. including the children subject of the
support order, times the number 01 children subject of the
support order)
b. Cash medical support obligation (Enter the amount on line 14b or
the amount of annual health care expenditures
United States Department of Agriculture

estimated by

and described in section

3119.30 of the Revised Code. whichever amount is lower). . . . . . ..

21. ADJUSTMENTS

TO CHILD SUPPORT WHEN HEALTH

INSURANCE

Father (only if obligor or shared parenting)

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

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

tine 19c. Col. I and line 208, Col. I

line lob times sum of amounts shown on

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

IS PROVIDED:

C. Subtractions;

1.289

Mother (only if obligor or shared parenting)

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

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

d, Subtractions:

_
line 16a times sum of amounts shown on

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

v,

DL624 EH~ttl", \ 0108

MoskOWitz & Mos;"owito:.

tlC

Prep.:lIrod

by J<:imc:;

H, Moskowitz.,

ESQ, Jame.s Mo~k.owitz

(c} FQmlly Low Software,

Inc. v 15.03 11120/2013 1:03pm

Hu~b3l\d.&

\Vita

Pogo 3

Order No.

Case No.

22. OBLIGATION

AFTER ADJUSTMENTS

Column I

Column 11

Father

Mother

TO CHILD SUPPORT WHEN HEALTH INSURANCE

IS PROVIDED:

a. Father: line 18a plus or minus the difference between line

$

21a minus line 21,c

9,668

b. Mother. line 18b plus or minus the difference between line

$

21b minus line 21d

23.

ACTUAL

ANNUAL

OBLIGATION

WHEN HEALTH

INSURANCE

23.229

IS PROVIDED:

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

$__

parent who is the obligor)

b. Any non-means-tested

--=9J.;,6:.;6:.::.8

$_---

benefits. including Social Security

and Veterans' benefits. paid 10 and received by a child or a

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

c. Actual annual obligation (Subtract line 23b from line 238). . . . . . . ..

24.

ADJUSTMENTS

TO CHILD SUPPORT WHEN HEALTH

INSURANCE

Father (only if obligor or shared parenting)

$__

.;;..0

--=9~,6:.:6:.::.8

$_---

$_---

IS NOT PROVIDED:
Mother (only if obligor or shared parenting)

b. Additions: line lob times sum of amounts shown on

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

line 19c, Col. Iand line 20b, Co/. I

line 19c. Col. If and line 20b. Col. If

$
379

c. Subtractions: line t6b times sum of amounts shown on

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

line 19c. Col. 1/and line 2Gb. Cof. /I

line 19c, Col. J and line 20b, Col. I

$
910

$.

25. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED:
a. Father: line 18a plus or minus the difference between line
24a minus line 24c

9,137

b. Mother. fine 18b plus or minus the difference between line

24b and fine 24d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
26.

ACTUAL

a.

ANNUAL

OBLIGATION

WHEN HEALTH

(Line 25a or 25b, whichever line corresponds

who is the obligor)

INSURANCE

23,229

IS NOT PROVIDED:

to the parent

,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

b. Any non-means-tested

9,137

$.

benefits, including Social Security

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

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

c. Actual annual obligation (Subtract line 26b from line 26a) . . . . . . . ..

9,137

27. a. Deviation from sole residential parent support amount shown on line 23c if amount would be unjust or inappropriate:
(see section 3119.;?3 of the Revised Code.) (Specific facts and monetary value must be stated.)
i. Sole custody deviation when health insurance is provided
40,000
ii. Sole custody deviation when health insurance NOT is provided

Dl624 Effective 101M

Moskowltz

B. MoskOWitz. lLC Prepared by James H. MoskOWItz..ESQ.James Moskowitz

(c) Family Law Software,

Inc. v 15.03 1112012013 1:03pm Husband &. Wife

_
_

Order No.

Case No.

b. Deviation from shared parenting order. (see sections 3119.23 and 3119.24 of the Revised Code.) (Specific facts including
amount of time children spend with each parent, ability of each parent /0 maintain adequate housing for children, and
each parent's expenses for children must be stated 10 juslify deviation.)
i. Shared custody deviation when health insurance is provided:
ii. Shared custody deviation when health insurance is NOT provided:

WHEN HEALTH

WHEN HEALTH

INSURANCE IS

INSURANCE IS

OBLIGOR

PROVIDED

NOT PROVIDED

Father/Mother

28. FINAL CHILD SUPPORT FIGURE:

(This amount reflects final annual child support obligation;
in Col. I, enter line 23c plus or minus any amounts indicated
in line 27a or 27b; in Col. II. enter line 26c plus or minus any,
amounts indicated in line

27a

or 27b) . . . . . . . . . . . . . . . . . . . . . ..

49,668

9,137

FATHER

----'--

29. FOR DECREE: Child support per month (Divide obligor's In 28., by 12)
... before any processing charge

. . . . . . . . . . . . . . . . . . . . . . . . ..

... 2% processing charge of

; ..

... including processing charge

$
$
$

4,139 $
8_3 $
4.222 $

-.:7....::6'-'.1
1..:..5
..:..7...:.7.c:,6

30. FINAL CASH MEDICAL SUPPORT FIGURE:

(This amount reflects the final. annual cash medical support
to be paid by the obligor when neither parent provides health
insurance coverage for the child; enter obligor's cash
medical support amount from fine 20b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

1,289

$
$

107
2

109

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

... 2% processing charge of

... including processing charge.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

Prepared by:
Counsel:

Pro se:
(For motherlfather)
Other.

CSEA:
Worksheet

Has Been Reviewed and Agreed To:

Mother

Date

Father

Date

0.624 EHecU...,

10108

Moskowitz & Mo,kow;'z, LLC PrOP"od by Jam es H. Moskowllz, Esq. James Moskowitz

(e) Family Law Softwa<e.lnc. v 15.0J 11/2012013

1:03pm Husband & Wil.

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