Instructions for Dissolution with Minor Children Background The “Petition” is a basic document for filing in a dissolution.

The “Petition” formally begins a lawsuit. The “Petition” and the accompanying documents are an agreement reached between your spouse and yourself. The “Petition” must be filed with the Court and a Waiver of Service of Summons needs to be executed in order to avoid additional court costs and the requirement of service. Completing the Petition The top section of the Petition (“caption”) contains identifying information about the case: the name of the case, case number, name of the document, and the name of petitioners. This information reappears at the top of each court document. Do not fill in the case number (Case No. _____-DS- _____) and the judge’s name. This information will be added by the Clerk of Courts when you file your case. You and your spouse begin the filing of the Petition and will always be known as “petitioners.” Print or type your name and address on the lines above the word petitioner No. 1 and then print or type your spouse’s name and address on the line above the word petitioner No. 2. Paragraph 1. Residency: This paragraph confirms to the court that you have been a resident of the State of Ohio for at least six (6) months to be eligible to file for dissolution. If you do not meet this requirement, then you are not eligible to file in this court unless your spouse meets both requirements at the time you file. Paragraph 2. Marriage: Print the name of the city or county where you were married and the date you were married. Paragraph 3. Children: This verifies that there are children of this marriage with their names and dates of birth. Paragraph 4. Pregnancy: Check whether or not the female spouse is pregnant. Paragraph 5. Separation Agreement: A Separation Agreement must be provided for the Court to consider a Petition for Dissolution of Marriage. It must be completed in full. The Separation Agreement should contain all assets and liabilities and how the petitioners wish to distribute said assets and liabilities. In the event that the petitioners will not enter into a Shared-Parenting Agreement, then the Separation Agreement must contain the information regarding parental rights and responsibilities, spousal support, child support and healthcare information. Paragraph 6. Shared-Parenting Agreement: If the petitioners wish to enter into a Shared Parenting Agreement it must be completed and contain all information set forth pursuant to both the outline and the agreement.

“Standard Parenting Time/Companionship/Visitation Schedule.” This is a guideline to assist you in filling out the Shared-Parenting Plan or the Separation Agreement that will provide for parenting time with your minor children. You are required to fill out “New Case Designation Form.” That form is self-explanatory.

In the event that you wish to file with a minimal court cost or no court costs, or are wishing to have the court costs waived, it is necessary to fill out Indigency Affidavit” and “Motion to Proceed without advancing Filing Fee Deposit.” In a dissolution you will need to fill out the “Waiver of Service of Summons” which is selfexplanatory. You will need to fill out the Judgment Entry of Dissolution form and bring it with you to your court hearing.

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) State: Defendant Information: First Name: Last Name: Address: City: SSN: Telephone: (if unrepresented) State:

Middle Initial: Suffix:

Middle Initial: Suffix:

Zip: DOB:

Zip: DOB:

□ Pro Se Plaintiff Attorney Information: Attorney Name: Ohio Sup Ct #: Telephone: Firm Name: Address: City: State: Zip:

Defendant Attorney Information: (if known) Attorney Name: Ohio Sup Ct #: Telephone: Firm Name: Address: City: State: Zip:

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:

____________________________________ Attorney for Plaintiff (or pro se litigant)

IN THE COURT OF COMMON PLEAS HOLMES COUNTY, OHIO ________________________________

Case No. ________________________ JUDGE _________________________ AFFIDAVIT OF INDIGENCY

Plaintiff,
VS ________________________________ Defendant,

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

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. OHIO Petitioner/Plaintiff CASE NO. 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 that said fees must be paid by one of the parties.IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION HOLMES COUNTY. I understand that this court cannot waive the payment of filing fees. I must pay the required cost deposit or the case/motion will be dismissed. Respectfully Submitted. and hereby moves this court for an order allowing him/her to proceed without advancing a filing fee deposit. JUDGE ROBERT D. Signature Printed Name Telephone Number: . 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 further understand that should this court deny this Motion. vs. As basis for this Motion.

______________________________________ Petitioner _____________________________________ Petitioner *** NEEDS WAIVER OF SERVICE OF SUMMONS Date: __________ Date: __________ . he parties have signed a separation agreement providing for allocation of parental rights and responsibilities.IN THE COURT OF COMMON PLEAS OF HOLMES COUNTY DOMESTIC RELATIONS DIVISION Name Street/P. State. _____ is currently pregnant. debts and liabilities. Zip Birth Date PETITIONER-2 One or both of the parties have been residents of the State of Ohio for at least six months preceding the filing of the Petition.O.O. _________. Box City. The parties were married on the _____ day of ___________. ROBERT D. The following minor children were born issue of the marriage: (1) ___________________ DOB _________ (4) _________________ DOB _______ (2) ___________________ DOB _________ (5) _________________ DOB _______ (3) ___________________ DOB _________ (6) _________________ DOB _______ the female petitioner: ____ is not currently pregnant. WHEREFORE. division of property. ____ (Check this box if it applies) The parties have reviewed the requirements of a Shared Parenting Plan contained in the Shared Parenting Outline and are asking the court to adopt their shared parenting plan which is attached hereto as a separate document. Box City. ________ at ___________________________. State. RINFRET JUDGE PETITION FOR DISSOLUTION OF MARRIAGE (WITH MINOR CHILDREN) Name Street/P. Zip Birth Date PETITIONER-1 And CASE NO. the parties petition the Court of a Decree of Dissolution of their marriage incorporating their Separation Agreement and Shared Parenting Plan if applicable. and spousal support (if any) and the same is attached and incorporated herein.

R. this affidavit must be filed by each party with every case that concerns minor children. 3119.IN THE COMMON PLEAS COURT OF HOLMES COUNTY. __________________________________ Defendant/Petitioner (2)/Respondent Address: ___________________________ ___________________________________ Phone: ____________________ Attorney: ___________________________ Attorney Address: ____________________ ___________________________________ Attorney Phone: _____________________ Notes: In accordance with Local Rules of this court. 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 Male / Female Age Residing with . You are under a continuing legal duty to file an updated version of this form if you learn of any additional information. regardless of whether child support or medical support will be paid. attach additional page(s). If more space is needed. _________________________ ___________________________________ Plaintiff/Petitioner (1) Address: ___________________________ ___________________________________ Phone: ____________________ Attorney: ___________________________ Attorney Address: ____________________ ___________________________________ Attorney Phone: _____________________ V. ___________________________________ (Your Name) Date of Prior Decree: ________________ (if applicable) JUDGE ROBERT D. RINFRET I.C. OHIO DIVISION OF DOMESTIC RELATIONS FINANCIAL AFFIDAVIT FOR COMPUTATION OF CHILD SUPPORT AND MEDICAL SUPPORT CASE NO. Information Required for Support Calculation: A.05. You will be required to provide proof of income per local rule and O.

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.) Private health insurance cost to you for your children (family plan cost less individual plan cost) Total number of dependents covered by your insurance Mother (All Figures Per Year) Yes No Yes No $ or % $ or % Father (All Figures Per Year) Any non-means tested benefits received by a child subject to this support order due to the death.B.6% of A. Not Living in My Household Child’s Name Date of Birth Male / Female Age Residing with II. This includes SSD. 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. disability.G. or Veteran’s benefits Mother (All Figures Per Year) .I. Other Minor Children of Mine. Other Minor Children Living in My Household Child’s Name Date of Birth Male / Female Age Relationship C. or retirement of the parent.

(If not known.R.R. Annual Overtime. 3119. expense-sharing. Put “EST” after each estimated figure. Bonuses (If not known. annuities. Put “EST” after each estimated figure. dividends. including pension. please estimate. royalties. reoccurring capital gains. trust income.C. Commissions. 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. Put “EST” after each estimated figure. AFDC. rents. social security.) Use Gross Annual Figures for Most Recent Full Year. interest. etc.C. Income [As defined in O. Year3 is Most Base Year3 is Most Commission. Zip Number of paychecks per year Year-to-date Gross Income □12 □ 24 □ 26 □ 52 Through date of □12 □ 24 □ 26 □ 52 Through date of Prior Year’s Tax Refund B. please estimate. Other Income All other income. spousal support received from a prior spouse. please estimate.) Father Describe Per Year Describe Mother Per Year Mother . disability benefits. Base Income Overtime.) Father Mother Overtime. See O. Gross Yearly Income from Employment (If not known. 3119. commissions. unemployment benefits. Put “EST” after each estimated figure. State. Gross Self-Employment Income (If not known. workers compensation. food stamps. Commission. actual or expected. SSI.) Father Mother Gross yearly employment income Employer Payroll Address City.01(C) Father Business Receipts Ordinary & Necessary Business Expenses Net Business Income D.01(C)]: A. please estimate.III.

_ I am not yet eligible to enroll in private health insurance through employment or another group policy.E. contract or plan. 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. etc. contract or plan that will cover the children. contract or plan.) ________________________________________________________________ LIST OF PLANS I have the following private health insurance policies. _ I declined enrollment of the child(ren) in health insurance available through my employer or another group policy. country club memberships. _ OTHER reason the child(ren) is/are not enrolled (explain): _____________________________________________________________________________ . stock options. etc. contracts or plans to cover the child(ren) available to me. Private Health Insurance Information CHECK ALL APPLICABLE BOXES AND FILL-IN ALL BLANKS. 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. _ I expect to enroll the child(ren) when I become eligible. but I will become eligible on (month/day/year) ____/____/______. My child(ren is/are covered by low-income government –assisted health care coverage (Healthy Start/Medicaid. but I am enrolled in a policy.) Father Mother Benefits Values Benefits Values IV. contract or plan for myself. Name of Insurance Company Entity/group through which policy. contract.

or pediatrician) accessible with this private health insurance: _ within 30 miles of the child(ren)’s home. Claims Phone No. 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.) 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).CURRENT PRIVATE HEALTH INSURANCE ENROLLMENT I DO HAVE the child(ren) enrolled in private health insurance through: _ an individual (non-group) policy. _ 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. (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). _ a group policy. internal medicine. (___) _______________________ Ins. 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. Provided through: _ Employer _ Current Spouse _ Other: ____________________________________________________________ Name of Policyholder: ____________________________ Insurance Co. contract or plan. Date child(ren) was/were enrolled in private health insurance: (month/day/year) ____/____/______. Claims address ____________________________ __________________________________________________ _________________________________________________ Policyholder Phone No. Co. family medicine physician. Co. contract or plan. (____) _____________________ Name of policy. _ because primary care services are only accessible by public transportation. Number of Dependents currently enrolled or who will be enrolled when I become eligible: _________ Name of Dependent Relationship to You ________________________________________________ _____________________________ ________________________________________________ _____________________________ ________________________________________________ _____________________________ ________________________________________________ _____________________________ ________________________________________________ _____________________________ . Name: ____________________________ Policyholder address: ____________________________ Ins.

Expenses. _____________________________________(print) hereby swear or affirm that the information set forth in this Affidavit of Income.22). List any additional factors or special circumstances you believe the court should consider. complete. ________________________________ AFFIANT Sworn to and subscribed before me this _____ day of ________________. 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.R. and that falsification of this document may also subject me to criminal penalties for perjury (O.V.C. ________________________________ Notary Public . and accurate. 2921. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ OATH OF AFFIANT I. ______. and Property above is true.

You must list the residences for all places where the children have lived for the last FIVE years. including Dissolutions. By law. PARENTING PROCEEDING AFFIDAVIT (R. add additional pages.COURT OF COMMON PLEAS HOLMES COUNTY. Child’s Name: Date of Birth: Place 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. Plaintiff/Petitioner Judge v. Minor child(ren) are subject to this case as follows: 2. RINFRET Defendant/Petitioner/Respondent Instructions: Check local court rules to determine when this form must be filed. safety. I request that the court not disclose my current address or that of the child(ren).C.C. If more space is needed. Insert the information requested below for all minor or dependent children of this marriage./and ROBERT D. My address is confidential pursuant to R. OHIO Case No. 3127.23(D) and should be placed under seal to protect the health. 3127. a.23(A)) Affidavit of (Print Your Name) Check and complete ALL THAT APPLY: 1. 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. Divorces and Domestic Violence Petitions. . or liberty of myself and/or the child(ren). Child’s Name: Date of Birth: Place of Birth: Sex: Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Male Female Period of Residence to to to to present Person(s) With Whom Child Lived (name & address) Relationship b. an affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court.

Period of Residence to to to to present Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Person(s) With Whom Child Lived (name & address) Relationship c. Period of Residence to to to to present Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Person(s) With Whom Child Lived (name & address) Relationship . Child’s Name: Date of Birth: Place 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.

concerning the custody of. 4. dependency. concerning the custody of. d.) I HAVE NOT participated as a party. I HAVE THE FOLLOWING INFORMATION concerning other civil cases that could affect the current case. ATTACH A SEPARATE PAGE AND CHECK THIS BOX . in this or any other state. or visitation (parenting time). c. with any child subject to this case. or in any capacity in any other case. b. Name of each child: Type of case: Court and State: Date and court order or judgment (if any): . witness. d. neglect or abuse allegations or adoptions concerning any child subject to this case.) I HAVE NO INFORMATION about any other civil cases that could affect the current case. domestic violence or protection orders. with any child subject to this case. domestic violence or protection orders. in this or any other state. including any cases relating to custody. c. including any cases relating to custody. witness. IF MORE SPACE IS NEEDED FOR ADDITIONAL CUSTODY CASES. . I HAVE participated as a party. ATTACH A SEPARATE PAGE AND CHECK THIS BOX 3. For each case in which you participated. b. give the following information: a. Participation in custody case(s): (Check only one box. dependency. or in any capacity in any other case. neglect or abuse allegations or adoptions concerning a child subject to this case. Explain: Name of each child: Type of case: Court and State: Date and court order or judgment (if any): a. Do not repeat cases already listed in Paragraph 3. Information about other civil case(s) that could affect this case: (Check only one box. or visitation (parenting time).IF MORE SPACE IS NEEDED FOR ADDITIONAL CHILDREN.

including guilty pleas. Name Case Number Court/State/County Convicted of What Crime? . Information about criminal case(s): List all of the criminal convictions.IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: .) 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. Claims custody rights Claims visitation rights Name of each child: b.C. 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. ATTACH A SEPARATE PAGE AND CHECK THIS BOX 6. ATTACH A SEPARATE PAGE AND CHECK THIS BOX 5. any sexually oriented offense as defined in R. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: c. 2919.01. IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES. a. 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. 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.25. Name/Address of Person Has physical custody . 2950. 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.

Notary Public My Commission Expires: . I understand that if I do not tell the truth. I may be subject to penalties for perjury. .OATH (Do Not Sign Until Notary is Present) I. the facts and information stated in this document are true. swear or affirm that I have read this document and. to the best of my knowledge and belief. (print name) . accurate and complete. Your Signature Sworn before me and signed in my presence this day of .

8. _______________________ request Child Support Services from the Holmes County Child Support Enforcement Agency. the CSEA and any of its contracted agents (e. town. in what city. The applicant can request “Location Services Only. D.APPLICATION FOR CHILD SUPPORT SERVICES NON-PUBLIC ASSISTANCE APPLICANT IMPORTANT: If you are receiving ADC or Medicaid. Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages. and to establish a medical support order. In providing IV-D services. if you were not married to the father of the child. The agency can obtain an order for the establishment of paternity (fatherhood). 7. . The agency can assist in finding where an absent parent is currently living.g. C. The Child Support Enforcement Agency can assist you in providing the following services: 1. prosecutors. The CSEA can assist you to obtain an order for support if you are separated. Collection and Disbursement of Payments. Location of Absent Parents. 3. I understand and agree to the following conditions: A. hearing officers. or need to establish paternity (fatherhood). I am a resident of the County in which services are requested. (See attached rights and responsibility information). The agency can assist you in collecting support if the payor is living in another state or in some foreign countries. Back support collected will be paid to you until all of the back support you are owed is paid. B. have been deserted. and send you a check for the amount of the payments received. attorneys. 5. Establishment of Paternity. The agency can help you get payroll deductions for current and back child support and can intercept unemployment compensation to collect child support. or state. The CSEA can also assist you in changing the amount of support orders (modification). 6. back support collected will be paid to the state after you receive back support owed to you. 2. An absent parent may request paternity services. Recipients of the child support services shall cooperate to the best of their ability with the CSEA. I the undersigned. etc. The CSEA can help you collect current and back child support. If you received ADC in the past and support was assigned to the state. Withholding of Wages and Unearned Income for the Payment of Court Ordered Support.. The CSEA can collect the child support for you. Some counties pay this fee for the applicants. Enforcement of Existing Orders. do not complete this application because you became eligible for child support services when you became eligible to receive ADC or Medicaid. The only fee you can be charged for services is a one dollar application fee.) 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.” if the sole need is to find the whereabouts of the absent parent. Interstate Collection of Child Support. Establishment or Modification of Child Support and Medical Support. The agency can assist in collecting back support (arrearages) by intercepting a non-payor’s federal and state income tax refunds on some cases. 4.

Is There an Order For Support □ Yes □ No Child 2 Telephone Number (Home) (Work) Child 3 Child 4 ABSENT PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT Absent Parent #1 Name Address (City. Zip Code INFORMATION ON CHILDREN Child 1 a. Zip Code) Amount of Support Ordered (Wk. Zip Code) SSN Date of Birth (DOB) Name of Employer Address of Employer (City.Name Social Security Number (SSN) APPLICANT INFORMATION (INFORMATION ABOUT YOU) Date of Birth □Single □Deserted Current Marital Status (Check One) □Married □Divorced □Widowed □Separated Type(s) of Service(s) Requested: All services listed Location of absent parent only Other (please explain) I understand that the Child Support Agency. Bi-Wk. Name(s) of Absent Parent f. State. Middle) Address (Street/Route. Gender c.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). Mo) Case Number on Support Order Absent Parent #2 Absent Parent #3 . Name b. State. State. Date of Birth (DOB) e. Box) City. Signature of Applicant Date Applicant’s Name (Last. SSN d. Has Paternity (Fatherhood) Been Established? g. P.O. First.

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? □ Yes □ No When (Date) Where (City and State) FOR AGENCY USE ONLY Case Name Case Number Date Requested Date Mailed or Provided County Date Returned or File Date . County.Date of Support Order Location Where Order Was Issued (City.

provide a copy of the order. Arrears amount? $____________ Do you pay spousal support to a former or current spouse? ______ How much do you pay? $________ 4. 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. Do you have any other minor children (NOT including stepchildren) for whom you are required to pay support? If so. If you are paying child support and/or spousal support on another case. Please print or type legibly A. If the question does not apply to you. write UNK (unknown). 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. how much do you pay a month? $_________ 3. please give their names and dates of birth: ____________________________________________________________________________________________________ __________________________________________ If yes. . write N/A (not applicable). Other Support Obligations 1.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. or if you do not know the answer.

or unemployment. 9. bonuses. showing your income and business expenses. Do you receive support for these children? ______ Amount per month? $___________ C. 2. Two Years ago $_____________ Last Year $____________ This year $_____________ 10. 6. Name of your present or most recent employer:_________________________________ Address of present or most recent employer: ___________________________________ Employer phone number: ____________________ Dates of employment: ______________ to _______________ How often are/were you paid? [ ] weekly [ ] every other week [ ] twice a month [ ] monthly [ ] other If “other”. Income 1. 3. 13. . 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. you MUST provide your tax documents. If you have been employed with present employer for less than one year. 4. 8. Overtime and/or Bonuses: Two Years ago $_____________ Last Year $____________ This year $_____________ 11. What is/was your hourly wage? $_________ Number of hours worked per week? ________ Overtime rate? $_________ Gross annual income from Employment / Self-Employment: *Do not include overtime. list previous employer and address: _________________________________________________ List hourly wage with previous employer: $________ Other Income for current year: Interest or Dividends: Unemployment Compensation Workers Compensation: Veteran’s Benefits: Other Pension: $_____________ $_____________ $_____________ $_____________ $_____________ 12.5. including a 1099 or Schedule C. please explain: __________________________________________________ 7. Are you Self Employed? _____ * If you answered ‘yes’ to this question. worker’s compensation.

Technical. child support may be calculated based on a determination of potential income. Vocational. 16. 2. 14. a determination will be made of your employment potential and probable earnings level. 4. D. E.Alimony: Tips: Social Security: Other $_____________ $_____________ $_____________ $_____________ please specify below ________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ *You must provide documentation of this income. W-2 and tax forms and pay stubs. If the agency should decide to impute income. what condition? __________________________________________ * Must provide medical documentation and an note from your physician which prohibits you from working. It is within the CSEA’s discretion to impute income on a case by case basis. Name and Location of College. Health Insurance: 1. Is the insurance provided through you or your current spouse? _____________ Name of your insurance company: _____________________________________ Address: _________________________________________________________ . Name and Location of High School: __________________________________________ Highest grade completed __________ 2. what City?________________ Do you have any medical conditions or disabilities which prohibit you from working?_____ *If yes. 1. 15. Do you provide health insurance for the child(ren) of this order? ____________ If yes. such as approval letter for SSI or SSD. or Trade School:______________ _______________________________________________________________________ Specialized training or skills: ________________________________________________ _______________________________________________________________________ Degrees obtained: ________________________________________________________ 3. 4. what is the annual cost for Family coverage? $ ______ Annual cost of single coverage? ______ * must provide cost of both plans 3. Do you receive public assistance? _________ In what County/ State? _______________ Amount of local income tax paid last year? ___________. Education / Training: If a parent is voluntarily unemployed or underemployed.

or school? ____ If yes. 20__. Do you provide childcare for the child(ren) of this action while you are at work. ___________________________ Notary Public THIS AFFIDAVIT MUST BE NOTARIZED . does you employer provide a health insurance plan? _______ If yes. training.Plan or Group Number ______________________ 5. how much do you pay? $________ *Provide proof of childcare expenses for credit. Do you pay mandatory work related expenses? If ‘yes’. If the child(ren) is/are not currently covered by insurance. 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 ___________. what is the annual cost for Family coverage? $ ______ Annual cost of single coverage? ______ Other: 1. 2.

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). ETC.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). ORC 3109. HOLIDAYS. the follow-up 30-day hearing must be set before a judge. PHYSICAL LIVING ARRANGEMENTS: This section needs to describe the regular living schedule of the child in each parent's home. 30 days must expire between the filing of the petition and plan and the granting of a final decree of shared parenting. 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. a specific provision must be included in a shared parenting plan for sharing the major holidays. 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. In the case of new. . In a shared parenting plan. birthdays. Optional provisions may be added. The Standard Order of Parenting Time may be incorporated in part or in whole in the plan. settled divorce cases. In post-decree matters. 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. By statute. this may be an appropriate section to provide for such changes. 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. Below. 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. VACATIONS. While it is not mandatory. both parents are legal custodians of the children. 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.: In spite of the fact that the living arrangements for the children may have been fully described. are those provisions which need to be included in a shared parenting plan. "Residential parent" means sole. legal custodian. and the use of the term "residential parent" for one parent only is contradictory to the shared parenting concept. etc. 2.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. the parties may wish to designate one party's home as the "primary residence" and another party's home as the "secondary residence". vacations. This is also the appropriate section to include any provision for visitation with grandparents or other relatives. 3. IT IS NOT APPROPRIATE TO DESIGNATE ONLY ONE OF THE PARENTS AS THE "RESIDENTIAL PARENT" IN A SHARED PARENTING PLAN.

For the most part. 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. medical expenses. school tuition. EMANCIPATION: Effective 1-1-98.24(B)(1) through (4) and read as follows: (i) The amount of time that the children spend with each parent..4. 5. it is by no means considered automatic for neither party to pay support just because it is a "shared parenting. lessons and extracurricular activities. (ii) The ability of each parent to maintain adequate housing for the children. provided. “AGREEMENTS TO AGREE” WHEN THE CHILDREN REACH SCHOOL AGE ARE NOT ACCEPTABLE. CHILD SUPPORT: A Sole Residential/Shared Parenting child support computation sheet must be prepared as part of a shared parenting plan. there are adequate provisions for all of the children's financial needs incorporated in the plan (See paragraph 6). there are some specific "extraordinary circumstances" applicable to shared parenting orders which are enumerated in R. you may wish to substitute a "Split Parental Rights" child support computation sheet to arrive at a more equitable child support order. THERE IS NO SEPARATE LEGISLATIVELY APPROVED "SHARED PARENTING" COMPUTATION OR FORMULA. however. 3119.” 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. the emancipation law in Ohio was revised as follows: “. 3119. camp or sports fees. Criteria for deviation from the guidelines are enumerated in R. . stated per child.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. 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.23 and in addition.C. 6.. and rounded off to the nearest dollar." Where a disparity of income exists and/or a disparity of physical care of the children exists. needs to be included.C.. SCHOOL: The statutory scheme mandates the designation of a school district. the exchange of child support is still considered appropriate and equitable. (iii) Each parent's expenses. It is common to have deviations from the child support guidelines in shared parenting cases. An acceptable alternative is to designate the school district where either the mother or father resides. The required statutory computation worksheet for shared parenting is the same worksheet that would be used in a sole custody situation. and dental expenses. 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.22 and 3119. 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. including but not limited to child care expenses. clothing.. including but not limited to employment-related child care. school fees. Child support must be stated in a monthly cycle only. only cases where there is equal income and equal time spent in each household will a lack of child support exchange be considered equitable. the order shall not remain in effect after the child reaches age nineteen. a provision for an appropriate sharing of financial expenses of the child or children. Deviations from the guideline-suggested amount must be explained in financial or monetary terms on line 27 of the computation sheet.

1 East Jackson Street. may be included in the shared parenting plan. No continuances of the hearing will be granted without written permission of the assigned judge or magistrate. It is the responsibility of the parent obtaining a restrictive order to serve it on the appropriate organization. the moving parent shall. and (2) Health Care Determinations form.7. 2) set a hearing. TAX EXEMPTIONS: Since both parties are custodial parents. 9. 12. 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. 10. which will be issued separately by the court. 11. A copy of the notice shall be provided to the Holmes County Common Pleas Court. with a provision for allocation of transportation expenses. If the parents are unable to agree. especially one which is provided as an employment benefit. 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. the tax law is of little assistance for determining who will be entitled to claim the children as dependents for tax purposes. 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. 8. unless a restrictive order has been obtained from the court. A reference to the Medical Support of Children Order. 13. and 3) obtain a modified visitation order. 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 may submit an agreed order modifying visitation. 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. both of which are available online. must be included as well as the attachment and incorporation by reference of the Private Heath Insurance Questionnaire and the Health Care Determinations form. prior to relocation. to the court for adoption by the court as an order. That issue must be addressed in the shared parenting plan. . if appropriate. PARENTS' LIFE INSURANCE FOR BENEFIT OF CHILDREN: The child/children or other parent needs to be made beneficiary of any existing life insurance plan. 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. The parties must complete the attached: (1) Private Heath Insurance Questionnaire. so long as the children remain unemancipated. Ohio 44654. Millersburg. 1) file a motion asking the court to modify the visitation schedule. RELIGIOUS TRAINING: Any agreement reached between the parents on religious training.

c. signed by both parties. encouragement of love and affection for the other parent.14.C. any modification shall be in writing. 15. 3109. b. modification shall be in accordance with R.04(E)(2)(a) or (b). Post high school education costs may be addressed in the plan as well as any other matter of importance to the parents. MISCELLANEOUS PROVISIONS: The parents may wish to include provisions concerning cooperation. . open communication. etc. The most typical provisions are: a. 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. MODIFICATION OF SHARED PARENTING PLAN: A method for modification of the shared parenting plan may be included in the plan.

Each parent is a caring and appropriate parent with the ability to provide guidance. by and between and hereinafter referred to as “Father” hereinafter referred to as “Mother” is submitted by Mother and/or Father pursuant to both parents’ Motion and/or request for Shared Parenting filed this same date. affection and contact between the minor children and each parent.25 involving a family member. 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.04 (D)(1)(a)(i. Neither parent expects opposition to this plan from the other.COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HOLMES COUNTY. pursuant to Ohio Revised Code section 3109. . Both parents hereby request the Court. 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. OHIO Case No. Neither parent has been convicted of or pleaded guilty to a violation of Ohio Revised Code section 2919. RINFRET -vs- SHARED PARENTING PLAN Defendant : This Shared Parenting Plan. any other offense which resulted in physical harm to a family member. Both parents have read the “Shared Parenting Outline” that is one of the Holmes County forms available online. 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. ii.: Plaintiff JUDGE ROBERT D. The provisions of this Shared Parenting Plan are entered into with those principles in mind. concern and a proper home environment for the minor children. or iii) to grant the parents the shared parenting of their child(ren): (Include dates of birth) .

The parents shall modify the schedule to meet the needs of the children. 1. 1.5 Each parent shall have time with the minor children on the children’s birthdays (set forth with specificity).4 Holidays with each parent shall be alternated. PHYSICAL LIVING ARRANGEMENTS 1. reasonable telephone contact is to be allowed. Upon receipt of the Notice. 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. 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.051(G)(2)(3) and (4).3 Father shall have the following parenting time:_________________________________ _____________________________________________________________________________ ______________________________________________________________________________ 1.1 Mother and Father shall be the residential parents without regard to where the children are physically located. under this Shared Parenting Plan must notify the Court of their intent to relocate and provide the Court with a new residence address promptly. The Standard Parenting Order is attached hereto and incorporated herein.2 Mother shall have the following parenting time:________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 1. the relocating parent. 1.9 1. Each parent will provide a bedroom(s) for the children separate from the parent’s room. In the event the parents disagree as to holidays.1. they shall utilize mediation or counseling before filing motions with the Court.10 The current address for Mother is: The current address for Father is: . they shall adopt the Standard Parenting Order as it relates to holidays.7 Mother and father shall have the minor children at any other time as agreed upon in advance between the parents. 1.8 If either parent desires to relocate. In the event they disagree as to modification. However.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. 1. 1.

RELIGION 6. Knox.1 All matters relating to child support. It is the parents’ intention to raise the minor child(ren) in the faith. (Form #15) 3. CHILD SUPPORT .2 4. CHANGE OF RESIDENCE OF MINOR CHILD 3. medical support and dependency exemptions shall be according to the attached separate document entitled “Judgment Entry Establishing Child Support and Medical Support”. Coshocton. Currently residence shall be used for school registration purposes.e. or that in the future may be. Tuscarawas counties) and establish residence for them in another county without first obtaining a court order or an agreed entry permitting such removal. Wayne.1 4. MEDICAL SUPPORT AND DEPENDENCY EXEMPTIONS 2.1 The parents shall consult as to the appropriate school placement for the minor child(ren). and thereafter be filed with the Holmes County Clerk of Courts. Ashland. day care provider or babysitter that is.1 The parents shall consult as to the appropriate religious education and training for the minor child(ren). and the Court.2. (Note: To have legal effect. ACCESS TO ALL OTHER RECORDS AND ACTIVITIES 4.3 Both parents shall be entitled to any and all other records related to the child (ren).) 4. their attorneys (if any). .1 Neither parent may remove the child(ren) from Holmes County or its contiguous Ohio counties (i. Both parents shall have access to any day care center. 5. 6. 5.2 Both parents recognize that the child(ren) legally may attend either parent’s school system. Both parents shall be entitled to attend student activities relating to the child (ren). an agreed entry must be signed by both parents. attended by the child(ren). It is the parents’ intent that the minor child(ren) attend public/private/parochial schools. SCHOOLS 5.

including times.2 Both parents acknowledge their responsibility to discuss activities important to the child(ren) in advance. in the event of any major disagreement between them relating to the minor child(ren) and prior to any court hearing. until the process is completed. no hearing shall be held. except by order of the Court. At the parents’ discretion. 7. in an effort to resolve all disagreements that they themselves are unable to resolve. seek co-parenting counseling. 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.1 shall provide transportation at commencement of parenting time and shall provide transportation at termination of said time. 9. The parties may file the appropriate motions prior to the completion of the process chosen. as agreed. dates and transportation needs. 8. However. 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.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. LIFE INSURANCE 9. unless they agree otherwise. 10. The parent who has the child(ren) will take the responsibility for transportation. The parents shall strive to maintain consistent methods of discipline in the child(ren)’s best interest.1 In an effort to implement the provisions of this order concerning shared parenting. MEDIATION 10. so that the child(ren) are not deprived of activities and maintaining friendships. 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. .1 The parents shall consult with each other regarding consistent and appropriate forms of discipline. a term policy in an equal face value amount may be substituted for the employment life insurance policy. or unless the Court orders costs allocated on some other basis. father and mother shall. to schedule activities and to school. The parties shall equally share the cost of any process chosen.7. mediation and/or non-binding arbitration with qualified individuals knowledgeable about the subject matter on which they disagree. TRANSPORTATION 7. DISCIPLINE 8.

051 of the Ohio Revised Code is in contempt of Court.1 12.052 are hereby waived.) section 3109.1 The Holmes County. Phone: ( )_____ _____ ) _____ 13. and there are no representations.2 Both parents have/have not at all times been represented by counsel. covenants. INCORPORATION INTO DECREE 15. MISCELLANEOUS 11.051 and 3109.2 Any keeper of any record who knowingly fails to comply with this plan. and any school official or employee who knowingly fails to comply with this order or division (J) of section 3109. CONTINUING JURISDICTION 13. 15. are not required. and an award of the moving party’s attorney fees and costs. as approved and adopted by the Court herein. 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. 12.4 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 3109.11.R.000. 14. or undertakings other than those expressly set forth.00 to $1. 11.051 of the Ohio Revised Code. shall be incorporated into a Shared Parenting Decree and entered as said Order of the Court.C. Ohio. 11.04.051 and 3109. . REPRESENTATION 12.1 This Shared Parenting Plan contains the entire Shared Parenting Plan and orders of this Court.0 fine.04. Mother is represented by Father is represented by . 3109. Phone: ( . Esquire. warranties.1 Findings of Fact and Conclusions of Law pursuant to Ohio Revised Code (O. a $250. 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. or a division (H) of section 3109.052. 3109. ENTIRE PLAN 14. or have been addressed elsewhere by the Court. Esquire.1 This Shared Parenting Plan.

as contact with both parents is important to children. (1) General Provisions. Any arguments or breaches of the peace shall bee treated as contempt of Court. (b) Visitation does not constitute the non-residential parent picking the children up and leaving them with someone other than a relative. Helping the children to find friends in the non-residential parent’s neighborhood also helps to make it like home for them. (a) Unless otherwise agreed in writing between the parties and subject to further order of this Court. (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. Activities the non-residential parent does with the children or skills taught to the children help the time to be rewarding. other than as required for employment.RESPECTFULLY SUBMITTED MOTHER FATHER DATE DATE ATTORNEY FOR MOTHER ATTORNEY FOR FATHER PARENTING TIME/COMPANIONSHIP/VISITATION SCHEDULES LOCAL RULE 25(A) (F) Visitation. Liberal visiting arrangements are encouraged. . Visitation is a time for children to do things with the parent they do not live with. Changes or modifications can be made by the Court if the need for such is shown. subparagraphs (2) and (3) set forth the minimum amount of visitation between the non-residential parent and the children. (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. Specific items in any journal entry of the Court take precedence over this rule.

m.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. (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 shall have the children for an additional six (6) days visitation.m. Martin Luther King Day 3. there are eight (8) holidays as follows: 1.m. Memorial Day 6. the residential parent shall have the children on Christmas Day and the non-residential parent shall have the children from 1:00 p. Fourth of July 7. Thanksgiving In the odd numbered years. to 9:00 p.m. the father shall have the children on the even numbered holidays.(e) The non-residential parent shall be responsible for transporting the children to and from visitation. the children shall be with the respective parent for a period of at least eight (8) hours. In addition. at Christmas time. the father shall have the children on the odd numbered holidays. President’s Day 4. Said visitation shall take place during the child(ren)’s Christmas vacation from school. The children shall be permitted to send and receive at least three letters or cards per week to or from the non-residential parent.m. Easter 5. the mother shall have the children on the odd number holidays.m. New Year’s Eve 2. the Court Orders that said visitation shall commence on Friday at 6:00 p. to be arranged for as soon as vacation schedules are posted for both parties to have an opportunity to take the children on vacation. (e) Each year at Christmastime. (during the school years) or 9:00 p. (f) On Mother’s Day and Father’s Day. no matter whose turn it is for visitation. Labor Day 8. on Christmas Eve. and shall conclude on Sunday at 6:00 p. . 3109. (g) The non-residential parent shall have a six (6) week visitation each summer. (d) For the purposes of visitation.C. The non-residential parent being late more than thirty (30) minutes shall operate as a forfeiture of that visitation period. (b) The non-residential parent shall have visitation one weeknight per week. In the event the parties are unable to agree as to the starting and ending time of said period. (during school vacation periods). In the even numbered years. (f) The children shall be permitted to speak on the telephone at least twice per week with the non-residential parent. until 7:30 p. and the mother shall have the children on the even numbered holidays. (2) Standard Visitation Guideline. Pursuant to R.m. if applicable. If the parties are unable to agree. then this midweek visitation shall be every Wednesday evening from 5:30 p.

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. (d) Summer Vacation:One-half of the school summer vacation. Labor Day 8. will be divided in half and alternated annually. and the mother shall have the children on the even numbered holidays and vacations. . excluding Christmas Eve and Christmas Day.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. (3) Standard Visitation Guidelines for Long-Distance Travel. Thanksgiving In the odd numbered years. between the parents. (c) Alternative Holidays: For the purposes of visitation. New Year’s Eve 2.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 second half. the mother shall have the children on the odd numbered holidays and vacations. (h) The children shall celebrate their birthdays in the home of the residential parent. the first half of the summer shall be spent with the non-residential parent. Fourth of July 7. there are eight holidays as follows: 1. (b) Spring Break: School vacation (the Friday school is out to the day before school recommences. In the even numbered years the father shall have the children on the odd numbered holidays and vacations. The non-residential parent must notify the residential parent as to his/her intentions by April 15. President’s Day 4. Pursuant to R. in the even numbered years. Summer school necessary for the children to pass to the next grade must be attended. father shall have the children on the even numbered holidays and vacations. and in the odd numbered years. The residential parent shall notify the non-residential parent by March 15 of when the summer vacation begins and ends. (i) If the parties cannot agree which half of the summer they prefer. 3109.C. Martin Luther King Day 3. by half. if practicable. Easter 5. 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. regardless of the non-residential parent’s visitation. Additionally. (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. Memorial Day 6. Christmas Eve and Christmas Day shall be alternated annually between the parents.

The residential parent must be notified at least one week in advance. Weekend visitation shall be as defined in Local R.(e) Each parent may arrange an uninterrupted vacation of not more than two (2) weeks with the children. including dates. . (g) Father’s Day and Mother’s Day shall always be spent with the appropriate parent. A general itinerary of the vacation shall be provided for the other parent. 25(F)(2)(a) and (c). locations. (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. addresses and telephone numbers.

whether acquired before. The parties to this Agreement represent the following: 1. and any rights to any interest in or to any property of the other. or _____ they desire immediate separation and intend to separate. and neither shall annoy. Husband and Wife. There are no minor children of the marriage. . Read this agreement carefully and completely before you sign it. interfere with or harass the other in any way or manner. between them.SEPARATION AGREEMENT This is an important legal document. either directly or indirectly. to determine all property rights. either by birth or adoption. any rights of inheritance from one another. 4. as to the duty of support to one another now or in the future. 2. one to another. and the Wife is not pregnant. or after marriage. The parties therefore agree as follows: ARTICLE ONE: Separation Each party shall hereafter live separate and apart from the other. during. Irreconcilable differences have arisen between the parties and (check one below) _____ they are now living separate and apart. This AGREEMENT is made between ______________________________ (name) and ________________________________ (name). They were married on _______________________ (date) in _______________________ (city and state). 3. molest. The parties intend this agreement to be a full and complete settlement of their rights. including property and debt distribution. and you may want to get the advice of an attorney. or other rights or benefits that may arise from the marital relationship.

whether refinancing is required. Household Goods. remarriage. The terms of this obligation are (include for what period. cohabitation. _____ _____ Neither party shall pay to the other any amount. whether the court can modify the amount or term): ARTICLE THREE: Division of Property and Debts. if to be sold. This provision may not be modified. A. whether one party has to sign a deed over to the other): B. if one party is keeping it. _____ _____ The ____ Husband or ____ Wife (check one) shall pay to the other party the sum of $_____________ weekly or monthly (indicate which) in spousal support. whether any payment is due the other for the equity in the house.ARTICLE TWO: Spousal Support (each party must initial applicable provision). for spousal support. how and what will happen to any proceeds. Furnishings and Personal Property (choose Option One or Two by both parties initialing) . 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.g. what events would terminate the obligation. either in installments or in a lump-sum. e. Real Estate (choose Option One or Two by both parties initialing) Option One: _____ _____ The parties own no real estate to divide.

and personal property now in that party's possession. now titled or registered in that party's name. 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). campers and other titled or registered conveyances. boats. furnishings. 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. _____the Wife (check one) will pay for that vehicle and . free of any claim of the other. and we agree that _____the Husband hold the other party harmless from liability. each party shall retain title to and possession of all motor vehicles and other forms of titled or registered conveyance. furnishings. both of us signed the note to pay for the vehicle. 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. 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. each party shall keep the household goods.Option One: ___ ___ Each party shall keep any households goods. i. Option Two: ___ ___ Except as listed here.e. and personal property in that party's possession. Option Two: ___ ___ Except as listed here.

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. 401(k) or other employer plans. Option Two: ___ ___ The parties agree to divide their bank accounts and employee benefits as follows (include details of how the accounts.D. 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. There are no joint accounts to be closed and/or divided. retirement. and which accounts. and the parties give up any interest in being named beneficiary of the other's policies. will be divided): E. Option Two: ___ ___ The parties agree as follows regarding their life insurance policies (identify the policies to which the agreement applies): . stock ownership. free and clear of any claim of the other.

release. allowance for year's support. and in all property rights that each now has. or the parties agree as follows (if left blank. exemption from administration. and discharge all claims and demands against the other. Each party is responsible for any attorney fees incurred by that party. and neither party shall incur any debt in the name of or on the credit of the other party. 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. There are no joint debts. except as specifically agreed in this Separation Agreement. heir. Please both initial to indicate your acceptance of this Article: _____ _____ . This Agreement is a full and complete settlement of all spousal support rights and property rights between the parties. the amount. satisfy. The court costs shall be paid from the deposit made with the Clerk of Courts.F. and next of kin. each of whom does. or may acquire in the future. inheritance. descent and distribution. ARTICLE FIVE: Complete Settlement. Option Two: ___ ___ The parties agree as follows regarding their debts (identify the debt. legatee. and all rights to administer the estate of the other. in the estate of the other. administrators. including rights of dower. all rights as surviving spouse. Debts (choose Option One or Two by both parties initialing) Option One: ___ ___ Each party shall pay those debts in that party's name. and the party who will be paying that debt): ARTICLE FOUR: Court Costs and Attorney Fees. the parties pay their own fees) _________________________________. executors and assigns. This Agreement shall be binding on the parties' heirs. by the provisions of this Agreement.

It is agreed and understood that this Agreement shall not constitute consent by either party to a divorce or dissolution of marriage. 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. each party shall execute or sign and shall deliver any and all deed. with the request that it be determined to be fair. Please both initial to indicate your acceptance of this Article: _____ _____ ARTICLE NINE: Modification of Agreement. or other documents necessary to carry out the terms of this Agreement. deliver to the other party. each party shall. Each party acknowledges that he or she has read all the terms and conditions of this Agreement and understands all the terms. or permit the other party to take possession of. This Agreement may only be modified in writing. No waiver or breach of any one term shall be considered a waiver of any other duty or right under this Agreement. all items of property to which each is entitled. or a properly certified copy of it. so that the other party could take that into account in negotiating this Agreement. in the event that either party files a divorce action or a dissolution proceeding is begun. and any other public and private officials are hereby authorized and directed to accept this Agreement. certificates. Except as otherwise provided in this Agreement. Each party further represents that he or she has made a full and disclosure of assets and liabilities. 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. 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: _____ _____ . Within fourteen (14) days after the journalization or filing of a decree of dissolution or divorce that incorporates this Agreement. earnings and benefits. and the County Auditor.ARTICLE SIX: Incorporation Into Decree. Please both initial to indicate your acceptance of this Article: _____ _____ ARTICLE EIGHT: Full Knowledge and Disclosure. titles. this Agreement shall constitute and operate as the properly executed document. Upon the failure of either party to deliver any document. and any modification must be signed by both parties. including any subsequent breach or default of a similar nature. upon the signing of this Agreement. whether modified or amended. just and proper. in lieu of the document regularly required for such conveyance or transfer. however. County Recorder. Please both initial to indicate your acceptance of this Article: _____ _____ ARTICLE SEVEN: Implementation of Agreement. and Clerk of Courts.

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 .

and related documents. HOLMES COUNTY. OHIO DOMESTIC RELATIONS DIVISION In the Matter of _________________________ Case No. RINFRET WAIVER OF SERVICE OF SUMMONS ________________________ Petitioners The Petitioners named above and signed below state that they are at least eighteen (18) years of age and not under any legal disability (that is. not having been determined to be incompetent for any reason) and that they have received copies of their Petition for Dissolution of Marriage. ______________________ Petitioner Dated:_________________ ______________________ Petitioner Dated:_________________ . and waive service of summons in accordance with the Ohio Rules of Civil Procedure. __________________ and JUDGE ROBERT D.IN THE COURT OF COMMON PLEAS.

The parties desire to dissolve their marriage. RINFRET Petitioner.(Separation Agreement attached hereto as Exhibit A).The parties were married on the date and at the place stated in the petition and _________ child(ren) have been born as issue of the marriage and the wife -is -is not now pregnant. Both parties waived their right to be represented by counsel. the Court makes the following findings: A. JUDGMENT ENTRY DECREE OF DISSOLUTION (WITH MINOR CHILDREN) Journalized: Journal _____ Page _____ (Please check the appropriate box(es) below: This case came on for hearing on the parties’ petition to dissolve their marriage on ___________. Petitioner. JUDGE ROBERT D. The parties have voluntarily entered into a separation agreement which makes a fair division of -all marital property and debt and -allocation of all parental rights and responsibilities . with both parties appearing in open court unrepresented by counsel. . CASE NO.Both parties were residents. -________________________ was a resident of the State of Ohio for at least six months prior to the filing of the petition for dissolution and the Court has jurisdiction to proceed in this matter. _________________________________________________________ 2. _________________________________________________________ C. After reviewing the submissions of the parties and taking the testimony of both parties.IN THE COURT OF COMMON PLEAS HOLMES COUNTY.SharedParenting Plan attached hereto as Exhibit B. . B. ___________ and ________________________. The child(ren)’s names with dates of birth are: NAMES DATE OF BIRTH 1. .Child Support Guidelines attached hereto as Exhibit C and Medical guidelines attached hereto as Exhibit D. . D. OHIO ________________________. 20__. . _________________________________________________________ 4. _________________________________________________________ 3.

B: [ ] Copies distributed on ___________________________________. SO ORDERED. (If a name change is desired. it is hereby Ordered. JUDGE -C to Parties . RINFRET. that Petitioner. It is further Ordered that the parties’ separation agreement is incorporated herein as if fully rewritten and made an order of the Court.A. . It is further Ordered that the costs of this action shall be taxed to the deposit and then to the parties equally. shall be restored to her prior name of ___________________. please fill out the name): It is further Ordered. DATED: ___________ cc w/Exhibit(s) _____________________________ ROBERT D.WHEREFORE. by ______. It is further Ordered that this is a final order. . Adjudged and Decreed that the marriage between the parties is hereby dissolved. __________________________.

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