MOTION FOR CHANGE OF PARENTAL RIGHTS AND RESPONSIBILITIES (CUSTODY… · 2015-11-06 · MOTION FOR...

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  • MOTION FOR CHANGE OF PARENTAL RIGHTS AND RESPONSIBILITIES (CUSTODY) SCIOTO COUNTY, OHIO

    You should only use these forms if there is already a custody order issued by the Domestic

    Relations Court. If you are filing a Motion for Change of Parental Rights and Responsibilities in a Domestic Relations Court case, the following forms must be filed:

    FORMS YOU MUST COMPLETE:

    Form Form Name Purpose and Instructions

    Domestic Relations Classification Form Required by the Court when filing this Motion. Put an “X” by DO and option E and/or G under DO. Fill out the bottom of the form.

    OH Sup. Ct. DR Form 24

    Motion for Change of Parental Rights and Responsibilities (Custody) and Memorandum in Support

    Required to request a change in the designation of the sole residential parent and legal custodian or to request a change in the shared parenting plan.

    OH Sup. Ct. DR Form 25

    Motion for Change of Child Support, Medical Support, Tax Exemption, or Other Child-Related Expenses and Memorandum in Support.

    Required IF you are also requesting a change in financial matters for custody

    OH Sup. Ct. Affidavit 1/

    Local Form 5

    Affidavit of Income and Expenses* Required to allow Courts to address child support and other related child expenses

    OH Sup. Ct. Affidavit 3

    Parenting Proceeding Affidavit* Required to advise the Court where the children have lived for the last five years and the names of the adults responsible for their care during this five year period. (or since birth if under age 5).

    Local Form 4 Application for Child Support Services (IV-D Application)

    Required if filing Motion for Change of Child Support

  • Local Form 12 Poverty Affidavit and

    Financial Disclosure/Affidavit of Indigency

    Tells the Court that you cannot afford to prepay the filing fee.

    OH Sup. Ct. Form 28

    Request for Service IF you do not know your spouse’s address AND you are filing a poverty affidavit, you must check the box for “Other” on this form and write in “posting” so the clerk will serve by posting.

    Required because the other party must be served with your Motion. This form tells the Court where to send the copies to the other party.

    OH Sup. Ct. Form 27

    Waiver of Service of Summons Complete this form IF the other party agrees to waive service of the Motion(s) by signing this form.

    Affidavit for Service* Use this ONLY if you do not know the other party’s current address.

    *Affidavits must be signed in front of a Notary who will administer an Oath

    INSTRUCTIONS

    • All forms must either be typed or printed in ink. You must fill out the forms completely before filing them with the court. The court staff will not help you complete the forms.

    • Make (1) copy of the following documents: o Domestic Classification form o Poverty Affidavit and Financial Disclosure/Affidavit of Indigency

    • Make three (3) copies of all other forms • Take the original and all copies to the Clerk of the Scioto County Common Pleas Court (2nd

    floor Courthouse on 6th street) • NOTE: If you did not complete the poverty affidavit, the filing fee is $_________ • Once you file the forms, the Clerk will send you notice of any court dates. You must attend

    all of these court dates. • NOTE: If you move, call the Clerk with your new address

    IF YOU ARE FILING THE MOTION FOR CHANGE, THEN YOU MUST ATTEND THE COURT HEARING.

  • IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION, SCIOTO COUNTY

    PORTSMOUTH OHIO

    CLASSIFICATION FORM

    Case No. Style: Please check the appropriate box(es):

    DR = Divorce

    A: Termination of Marriage with Children

    B: Termination of Marriage without Children

    DM = Dissolution

    C: Dissolution of Marriage with Children

    D: Dissolution of Marriage without Children

    DV = Domestic Violence DO = Other Domestic Relations Matters

    E: Change of Custody F: Visitation Enforcement/Modification G: Child Support Enforcement/Modification I: U.I.F.S.A. J: Parentage K: All Others

    Submitted By: Address: Telephone:

  • IN THE COURT OF COMMON PLEAS Division COUNTY, OHIO IN THE MATTER OF:

    A Minor

    : Name : Case No. : Street Address : : Judge City, State and Zip Code :

    Plaintiff/Petitioner : : Magistrate : vs. : : : Name : : Street Address : : City, State and Zip Code :

    Defendant/Petitioner : Instructions: This form is used to request a change in a shared parenting plan or a change in the designation of the sole residential parent and legal custodian. A Request for Service (Uniform Domestic Relations Form 28) and a Parenting Proceeding Affidavit (Uniform Domestic Relations Form – Affidavit 3) must be filed with this Motion.

    MOTION FOR CHANGE OF PARENTAL RIGHTS AND RESPONSIBILITIES (CUSTODY) AND MEMORANDUM IN SUPPORT

    1. I, (name), request this Court change the allocation of

    parental rights and responsibilities (custody) Order filed on this date (filed date) regarding the following minor child(ren): Name of Child Date of Birth

    Page 1 of 2 Supreme Court of Ohio Uniform Domestic Relations Form – 24 Uniform Juvenile Form – 6 MOTION FOR CHANGE OF PARENTAL RIGHTS AND RESPONSIBILITIES (CUSTODY) AND MEMORANDUM IN SUPPORT Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • 2. Select one:

    (name) is currently designated as the residential parent and/or legal custodian of the children and resides in the School District. The parents now have a Shared Parenting Plan. 3. The circumstances have changed since the Court issued the existing order. The change in

    circumstances and any other reason for the requested change are as follows:

    4. I request that the Court change the existing order in the following way:

    5. I believe that the changes I am requesting are in the child(ren)’s best interests.

    Your Signature

    Telephone number at which the Court may reach you

    or at which messages may be left for you

    Page 2 of 2 Supreme Court of Ohio Uniform Domestic Relations Form – 24 Uniform Juvenile Form – 6 MOTION FOR CHANGE OF PARENTAL RIGHTS AND RESPONSIBILITIES (CUSTODY) AND MEMORANDUM IN SUPPORT Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • IN THE COURT OF COMMON PLEAS Division COUNTY, OHIO IN THE MATTER OF:

    A Minor

    : Name : Case No. : Street Address : : Judge City, State and Zip Code :

    Plaintiff/Petitioner : : Magistrate : vs. : : : Name : : Street Address : : City, State and Zip Code :

    Defendant/Petitioner : Instructions: This form is used to request a change in the child support or child support-related matters. A Request for Service (Uniform Domestic Relations Form 28) and an Affidavit of Income and Expenses (Uniform Domestic Relations Form–Affidavit 1) must be filed with this Motion.

    MOTION FOR CHANGE OF CHILD SUPPORT, MEDICAL SUPPORT, TAX EXEMPTION, OR OTHER CHILD-RELATED EXPENSES

    AND MEMORANDUM IN SUPPORT

    I, (name), request this Court change my obligation to provide support or my right to receive support for the minor child(ren) as follows (check all that apply):

    1. The amount of child support to be paid each month. The change I want the Court to order is:

    Page 1 of 2 Supreme Court of Ohio Uniform Domestic Relations Form – 25 Uniform Juvenile Form – 7 MOTION FOR CHANGE OF CHILD SUPPORT, MEDICAL SUPPORT, TAX EXEMPTION, OR OTHER CHILD-RELATED EXPENSES AND MEMORANDUM IN SUPPORT Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • 2. The person responsible for providing health insurance for the child(ren). The change I want the Court to order is:

    3. The amount of non-insured health care expenses of the minor child(ren) that I have to pay.

    The change I want the Court to order is:

    4. The person who can claim the child(ren) as tax dependents. The change I want the Court to

    order is:

    5. Other child-related expenses. The change I want the Court to order is:

    6. The circumstances have changed since the Court issued the existing order. The change in

    circumstances and any other reason for the requested change are as follows:

    7. I believe that the requested changes are in the child(ren)'s best interests.

    Your Signature

    Telephone number at which the Court may reach you or at which messages may be left for you

    Page 2 of 2 Supreme Court of Ohio Uniform Domestic Relations Form – 25 Uniform Juvenile Form – 7 MOTION FOR CHANGE OF CHILD SUPPORT, MEDICAL SUPPORT, TAX EXEMPTION, OR OTHER CHILD-RELATED EXPENSES AND MEMORANDUM IN SUPPORT Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • COURT OF COMMON PLEAS COUNTY, OHIO

    Case No. Plaintiff/Petitioner

    Judge

    v./and Magistrate

    Defendant/Petitioner

    Instructions: Check local court rules to determine when this form must be filed. This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write “none” where appropriate. If you do not know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages.

    AFFIDAVIT OF INCOME AND EXPENSES

    Affidavit of (Print Your Name)

    Date of marriage Date of separation

    SECTION I - INCOME Husband Wife

    Employed Yes No Yes No

    Employer

    Payroll address

    Payroll city, state, zip

    Scheduled paychecks per year 12 24 26 52 12 24 26 52

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

    Husband Wife

    Base yearly income $ 3 years ago 20 $

    $ 2 years ago 20 $

    $ Last year 20 $

    Yearly overtime, commissions and/or bonuses

    $ 3 years ago 20 $

    $ 2 years ago 20 $

    $ Last year 20 $

    B. COMPUTATION OF CURRENT INCOME

    Husband Wife Base yearly income $ $

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 1 of 7

  • Average yearly overtime, commissions and/or bonuses over last 3 years (from part A) $ $ Unemployment compensation $ $ Disability benefits

    $ $

    Workers’ Compensation

    Social Security

    Other: Retirement benefits

    $ $

    Social Security

    Other: Spousal support received $ $ Interest and dividend income (source)

    $ $

    Other income (type and source)

    $ $

    TOTAL YEARLY INCOME $ $

    Supplemental Security Income (SSI) or public assistance $ $ Court-ordered child support that you receive for minor and/or dependent child(ren) not of the marriage or relationship $ $

    SECTION II – CHILDREN AND HOUSEHOLD RESIDENTS Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship:

    Name Date of birth Living with

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 2 of 7

  • In addition to the above children there is/are in your household:

    adult(s)

    other minor and/or dependent child(ren). SECTION III – EXPENSES List monthly expenses below for your present household. A. MONTHLY HOUSING EXPENSES

    Rent or first mortgage (including taxes and insurance) $

    Real estate taxes (if not included above) $

    Real estate/homeowner’s insurance (if not included above) $

    Second mortgage/equity line of credit $

    Utilities

    o Electric $

    o Gas, fuel oil, propane $

    o Water and sewer $

    o Telephone $

    o Trash collection $

    o Cable/satellite television $

    Cleaning, maintenance, repair $

    Lawn service, snow removal $

    Other: $ $

    TOTAL MONTHLY : $

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 3 of 7

  • B. OTHER MONTHLY LIVING EXPENSES

    Food

    o Groceries (including food, paper, cleaning products, toiletries, other) $

    o Restaurant $

    Transportation

    o Vehicle loans, leases $

    o Vehicle maintenance (oil, repair, license) $

    o Gasoline $

    o Parking, public transportation $

    Clothing

    o Clothes (other than children’s) $

    o Dry cleaning, laundry $

    Personal grooming

    o Hair, nail care $

    o Other $

    Cell phone $

    Internet (if not included elsewhere) $

    Other $

    TOTAL MONTHLY $

    C. Monthly child related expenses (for children of the marriage or relationship)

    Work/education-related child care $

    Other child care $

    Unusual parenting time travel $

    Special and unusual needs of child(ren) (not included elsewhere) $

    Clothing $

    School supplies $

    Child(ren)’s allowances $

    Extracurricular activities, lessons $

    School lunches $

    Other $

    TOTAL MONTHLY $

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 4 of 7

  • D. INSURANCE PREMIUMS

    Life $

    Auto $

    Health $

    Disability $

    Renters/personal property (if not included in part A above) $

    Other $

    TOTAL MONTHLY $

    E. MONTHLY EDUCATION EXPENSES

    Tuition

    o Self $

    o Child(ren) $

    Books, fees, other $

    College loan repayment $

    Other $

    $

    TOTAL MONTHLY: $

    F. MONTHLY HEALTH CARE EXPENSES (not covered by insurance)

    Physicians $

    Dentists $

    Optometrists/opticians $

    Prescriptions $

    Other $

    $

    TOTAL MONTHLY: $

    G. MISCELLANEOUS MONTHLY EXPENSES

    Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) $

    Child support for children who were not born of this marriage or relationship and were not adopted of this marriage $

    Spousal support paid to former spouse(s) $

    Subscriptions, books $

    Entertainment $

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 5 of 7

  • Charitable contributions $

    Memberships (associations, clubs) $

    Travel, vacations $

    Pets $

    Gifts $

    Bankruptcy payments $

    Attorney fees $

    Required deductions from wages (excluding taxes, Social Security and Medicare) (type) $

    Additional taxes paid (not deducted from wages) (type) $

    Other $

    $

    TOTAL MONTHLY: $

    H. MONTHLY INSTALLMENT PAYMENTS (Do not repeat expenses already listed.) Examples: car, credit card, rent-to-own, cash advance payments

    To whom paid Purpose Balance due Monthly payment

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $

    $ $ TOTAL MONTHLY: $

    GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 6 of 7

  • OATH

    (Do not sign until notary is present.)

    I, (print name)

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

    Your Signature

    Sworn before me and signed in my presence this day of , .

    Notary Public

    My Commission Expires:

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 1 Affidavit of Income and Expenses Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 7 of 7

  • COURT OF COMMON PLEAS

    COUNTY, OHIO

    Case No. Plaintiff/Petitioner

    Judge

    v./and Magistrate

    Defendant/Petitioner/Respondent

    Instructions: Check local court rules to determine when this form must be filed. By law, an affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court, including Dissolutions, Divorces and Domestic Violence Petitions. Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, add additional pages.

    PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) Affidavit of

    (Print Your Name) Check and complete ALL THAT APPLY: 1. I request that the court not disclose my current address or that of the child(ren). My address is

    confidential pursuant to R.C. 3127.23(D) and should be placed under seal to protect the health, safety, or liberty of myself and/or the child(ren).

    2. Minor child(ren) are subject to this case as follows:

    Insert the information requested below for all minor or dependent children of this marriage. You must list the residences for all places where the children have lived for the last FIVE years.

    a. Child’s Name: Place of Birth:

    Date of Birth: Sex: Male Female

    Period of Residence Check if Confidential Person(s) With Whom Child Lived

    (name & address) Relationship

    to present Address Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 3 Parenting Proceeding Affidavit Page 1 of 4 Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010

  • b. Child’s Name: Place of Birth:

    Date of Birth: Sex: Male Female

    Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.

    Period of Residence Check if Confidential Person(s) With Whom Child Lived

    (name & address) Relationship

    to present Address Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    c. Child’s Name: Place of Birth:

    Date of Birth: Sex: Male Female

    Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.

    Period of Residence Check if Confidential Person(s) With Whom Child Lived

    (name & address) Relationship

    to present Address Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    to

    Address

    Confidential?

    IF MORE SPACE IS NEEDED FOR ADDITIONAL CHILDREN, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .

    3. Participation in custody case(s): (Check only one box.) I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other

    state, concerning the custody of, or visitation (parenting time), with any child subject to this case.

    I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of, or visitation (parenting time), with any child subject to this case. For each case in which you participated, give the following information:

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 3 Parenting Proceeding Affidavit Page 2 of 4 Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010

  • a. Name of each child: b. Type of case: c. Court and State: d. Date and court order or judgment (if any): IF MORE SPACE IS NEEDED FOR ADDITIONAL CUSTODY CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .

    4. Information about other civil case(s) that could affect this case: (Check only one box.) I HAVE NO INFORMATION about any other civil cases that could affect the current case, including

    any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case.

    I HAVE THE FOLLOWING INFORMATION concerning other civil cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning a child subject to this case. Do not repeat cases already listed in Paragraph 3. Explain:

    a. Name of each child: b. Type of case: c. Court and State: d. Date and court order or judgment (if any): IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX . 5. Information about criminal case(s): List all of the criminal convictions, including guilty pleas, for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any domestic violence offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense.

    Name Case Number Court/State/County Convicted of What Crime?

    IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 3 Parenting Proceeding Affidavit Page 3 of 4 Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010

  • 6. Persons not a party to this case who has physical custody or claims to have custody or visitation

    rights to children subject to this case: (Check only one box.) I DO NOT KNOW OF ANY PERSON(S) not a party to this case who has/have physical custody or

    claim(s) to have custody or visitation rights with respect to any child subject to this case.

    I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case.

    a. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: b. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: c. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child:

    OATH

    (Do Not Sign Until Notary is Present)

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

    Your Signature

    Sworn before me and signed in my presence this day of , .

    Notary Public

    My Commission Expires:

    Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 3 Parenting Proceeding Affidavit Page 4 of 4 Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010

  • SCIOTO COUNTY DR FORM 4 Scioto Co. CSEA 710 Court Street PO Box 1347 Portsmouth, Ohio 45662 740-355-8904 800-354-6377 Name: Address:

    APPLICATION FOR CHILD SUPPORT SERVICES NON-PUBLIC ASSISTANCE APPLICANT/RECIPIENT

    IMPORTANT: If you are receiving ADC or Medicaid, do not complete this application because you became eligible for child support services when you signed the ADC/Medicaid application. I, request child support services from the Scioto County CSEA (Child Support Enforcement Agency). I understand and agree to the following: A. I am a resident of the county in which services are requested and no other Ohio county has jurisdiction over support –OR –I

    am requesting services from the Ohio county of jurisdiction.

    B. The only fee that can be charged for services is a one dollar application fee. Some counties pay this fee for the applicants.

    C. Recipients of child support services shall cooperate to the best of their ability with the CSEA. (See attached rights and responsibility information).

    D. In providing IV-D services, the CSEA and any of its contracted agents (e.g., prosecutors, attorneys, hearing officers, etc.) represent the best interest of the children of the state of Ohio and do not represent any IV-D recipient or the IV-D recipient's personal interest.

    The Child Support Enforcement Agency can assist you in providing the following services: 1. Location of Absent Parents.

    The agency can assist in finding where an absent parent is currently living, in what city, town, or state. The applicant can request 'Location Only Services', if the sole need is to find the whereabouts of the absent parent.

    2. Establishment or Adjustment of Child Support and Medical Support.

    The CSEA can assist you to obtain an order for support if you are separated, have been deserted, or need to establish paternity (fatherhood). The CSEA can also assist you in changing the amount of support orders (adjustment), and to establish a medical support order.

    3. Enforcement of Existing Orders. The CSEA can help you collect current and past-due child support. 4. Federal and State Income Tax Refund Offset Submittals for the Collection of Child Support Arrearages.

    The agency can collect past-due support (arrearages) by intercepting a payor's federal and state income tax refunds in some cases.

    5. Withholding of Wages and Unearned Income for the Payment of Court Ordered Support.

    The agency can help you get payroll deductions for current and past-due child support and can intercept unemployment compensation to collect child support.

    6. Establishment of Paternity.

    The agency can obtain an order for the establishment of paternity (fatherhood), if you were not married to the father of the child. An absent parent may request paternity services.

    7. Collection and Disbursement of Payments.

    The CSEA can collect the child support for you, and send you a check for the amount of the payments received. Past due support collected will be paid to you until all of the past-due support you are owed is paid.

    8. Interstate Collection of Child Support.

    The agency can assist you in collecting support if the payor is living in another state or in some foreign countries.

    JFS 07076 Page 1 of 4

  • APPLICANT INFORMATION

    Name: Date of Birth:

    Home Address: Mailing Address:

    Home Phone #:

    Social Security #: Sex:

    Race:

    Single Married

    Relationship to Children: Divorced Separated

    Military Service Ever Been on Public

    (Branch, Dates) Assistance?

    (When, Where)

    EMPLOYER INFORMATION

    Employer Name: Employer Phone #:

    Employer: Is Medical Insurance

    Address: Available?

    CHILD 1 CHILD 2 CHILD 3

    Name:

    Sex:

    Race:

    Social Security #:

    Date of Birth:

    Home Address:

    Location of Birth: (country, State, city)

    JFS 07076 Page 2 of 4

  • Has Paternity (fatherhood) Been Established?

    Name(s) of absent parent(s):

    Is there an Order for Support?

    Is the child covered by medical insurance?

    ABSENT PARENT INFORMATION

    Absent Parent #1

    Absent Parent #2

    Absent Parent #3

    Name (and alias):

    Home Address:

    Mailing Address:

    SSN:

    Date of Birth (DOB)

    Location of Birth: (Country, State, city)

    Race:

    Sex:

    Height/Weight:

    Hair/Eye Color:

    Identifying Marks: (tattoos, scars, etc.)

    Names of Children:

    Name of Employer:

    Address of Employer: (City, State, Zip Code)

    Employer Phone #:

    JFS 07076 Page 3 of 4

  • Medical Insurance Provided?

    Support Order #:

    Date of Support Order:

    Amount of Support: $

    $

    $

    Order Frequency:

    Per

    Per Per

    Location Where Order Issued:

    Military Service (Branch, Dates):

    Ever Incarcerated? (Location, Dates):

    Arrest Record: (Location, Dates):

    Current Spouse: (Name, Address)

    Father’s Name:

    Mother’s Name: (maiden)

    Ever been on Public Assistance? (Location, Dates)

    Type(s) of Service(s) Requested:

    All Services Listed

    Location of absent parent only

    Other (please explain):

    I understand that the Child Support Agency within 20 days of receiving this application will contact me by written notice to inform me if my case has been accepted for child support services (IV-D Services). Signature of Applicant: _____________________________________ Date:_______________________________

    JFS 07076 Page 4 of 4

  • Scioto County DR Form 12

    IN THE SCIOTO COUNTY COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION, SCIOTO COUNTY

    PORTSMOUTH, OHIO

    PLAINTIFF

    v.

    DEFENDANT

    CASE NUMBER: JUDGE JERRY L. BUCKLER MAGISTRATE MICHAEL L. JONES

    PETITION FOR WAIVER OF PREPAYMENT OF FILING FEE AND COUT COSTS DEPOSIT WITH POVERTY AFFIDAVIT

    Please mark one of the following boxes and fill in the appropriate information:

    □ I, _______________________, am the Plaintiff/Defendant in the above-captioned case.

    Or

    □ We, ___________________________ and ___________________________, are the Petitioners in the above-captioned case.

    I/We request the Court grant a Waiver of the Prepayment of the Filing Fee and Court Costs Deposit so that this case can proceed without the initial payment or deposit of any fees.

    Telephone No.

    Telephone No.

  • In support of my/our petition under Ohio R.C. §2323.31, the attached affidavit(s) is/are submitted. I/We understand that this petition could be denied and a deposit or fee may have to be paid. If not paid, this case may be dismissed. I/We understand that even if granted, the Court may assess costs against me/us after the case is over. ___________________________ Plaintiff/Petitioner ___________________________ Defendant/Petitioner STATE OF OHIO ) ) SS. POVERTY AFFIDAVIT SCIOTO COUNTY ) I/We, __________________________________, being duly sworn sayeth:

    1. I am a party in the foregoing action; 2. I am without the funds or assets to give security or a cash deposit to secure

    costs at this time. 3. I understand that I must inform the court if my financial situation should

    change before the disposition of my case; 4. I understand that I am subject to criminal charges for providing false

    information; 5. I understand that if it is determined by the court, that I was not entitled to the

    suspended deposit/costs that were provided to me, I may be required to reimburse the county for the costs;

    6. I understand that the court will ultimately determine which party will be responsible for the payment of costs in this case, unless costs are waived.

    _____________________________ Affiant Sworn before me and subscribed in my presence this __________________ day of _________________, 20 _________ . _____________________________ Notary public or Deputy Clerk

  • FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY

    ($25.00 application fee may be assessed – see notice on reverse side) I.PERSONAL INFORMATION

    Name/Applicant

    Party Represented (if applicant enter “same)

    DOB:

    Mailing Address

    City State Zip

    Case No.

    Phone ( )

    Message Phone (within 48 hours) ( )

    II. OTHER PERSONS LIVING IN HOUSEHOLD Name 1)

    DOB Relationship Name 3)

    DOB Relationship

    2)

    4)

    III. MONTHLY INCOME/EMPLOYMENT INFORMATION Type of Income Applicant Spouse (or Parents if

    application is a juvenile) Other Household Members

    Total

    Employment (Gross) Unemployment Worker’s Comp Pension/Social Security Child Support Works First/TANF Disability Other

    Employer’s Name (for all household members)

    A.TOTAL INCOME $

    Phone ( )

    IV. ALLOWABLE EXPENSES V. TOTAL INCOME Type of Expense Amount Child Support Paid Out Child Care (if working only) Total Income – Allowable Expenses = Adjusted Total Income Transportation for work Insurance A.TOTAL INCOME $ Medical Dental - B.EXPENSES $ Medical & Associated Costs of Caring for Infirm Family members

    = C.ADJUSTED TOTAL INCOME $

    B. EXPENSES $

    VI. ASSET INFORMATION Type of Asset Describe/Length of Ownership/Make, Model, Year (where applicable) Estimated Value Real Estate/Home Price:$ Date Purchased: Amt. Owed $: Stocks/Bonds/CD’s Automobiles Trucks/Boats/Motorcycles Other Valuable Property Cash on Hand Money Owed to Applicant Other Checking Acct. (Bank/Acct #) Savings/MM Acct. (Bank/Acct #)

    D. TOTAL ASSETS $

    Page 1 of 2

  • VII. MONTHLY LIABILITIES/OTHER EXPENSES VIII. GRAND TOTALS

    Type of Liability Amount

    Rent / Mortgage

    Food C. ADJ. TOTAL INCOME Electric Gas D. TOTAL ASSETS Fuel

    Telephone E. LIABILITIES & OTHER

    Cable

    Water / Sewer / Trash $25.00 APPLICATION FEE NOTICE Credit Cards By submitting this Financial Disclosure Form/Affidavit of

    Indigency Form, you will be assessed a non-refundable $25.00 application fee unless waived or reduced by the court. If assessed, the fee is to be paid to the clerk of courts within seven (7) days of submitting this form to the court, the public defender, your appointed counsel or any other party who will make a determination regarding your indigency.

    Loans Taxes Owed Other

    E. LIABILITIES & OTHER EXPENSE IX. AFFIDAVIT OF INDIGENCY

    I, _______________________________________________________(affiant) being duly sworn, say:

    1. I am financially unable to retain private counsel without substantial hardship to me or my family.

    2. I understand that I must inform the public defender or appointed attorney if my financial situation should change before the disposition of the case(s) for which representation is being provided.

    3. I understand that if it is determined by the county, or by the Court, that legal representation should not have been provided, I may be required to reimburse the county for the costs of representation provided. Any action filed by the county to collect legal fees hereunder must be brought within two years form the last date legal representation was provided.

    4. I understand that I am subject to criminal charges for providing false financial information in connection with the above application for legal representation pursuant to Ohio Revised Code Sections 120.05 and 2921.13.

    5. I hereby certify that the information I have provided on this financial disclosure form is true to the best of my knowledge.

    Affiant’s Signature Date Notary Public/Individual duly authorized to administer oath: Subscribed and duly sworn before me according to law, by the above named applicant this ______ day of

    _______________________, _______, at _______________________, County of _______________________ and State of _________________.

    Signature of person administering oath Title

    X. JUDGE CERTIFICATION I hereby certify that above-noted applicant is unable to fill out and/or sign this financial disclosure/ affidavit for

    the following reason: __________________________________________________________________________.

    I have determined that the applicant meets the criteria for receiving court appointed counsel. Judge’s Signature Date

    Page 2 of 2

  • IN THE COURT OF COMMON PLEAS Division COUNTY, OHIO IN THE MATTER OF:

    A Minor

    : Name : Case No.

    :

    Street Address : Judge : City, State and Zip Code :

    Plaintiff/Petitioner : Magistrate : vs./and : : : Name : : Street Address : : City, State and Zip Code :

    Defendant/Petitioner : Instructions: This form is used when you want to request documents to be served on the other party. You must indicate the requested method of service by marking the appropriate box.

    REQUEST FOR SERVICE TO THE CLERK OF COURT: Please serve the following documents on the following parties as I have indicated below:

    Defendant/Petitioner at the address shown above. Certified Mail, Return Receipt Requested Issuance to Sheriff of County, Ohio for Personal or Residence service Other (specify)

    Supreme Court of Ohio Uniform Domestic Relations Form – 28 Uniform Juvenile Form – 10 Page 1 of 2 REQUEST FOR SERVICE Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • Plaintiff/Petitioner at the address shown above. Certified Mail, Return Receipt Requested Issuance to Sheriff of County, Ohio for Personal or Residence service Other (specify)

    County Child Support Enforcement Agency (provide address below): Certified Mail, Return Receipt Requested Issuance to Sheriff of County, Ohio for Personal or Residence service Other (specify)

    Other (address): Certified Mail, Return Receipt Requested Issuance to Sheriff of County, Ohio for Personal or Residence service Other (specify) SPECIAL INSTRUCTIONS TO SHERIFF: Your Signature

    Supreme Court of Ohio Uniform Domestic Relations Form – 28 Uniform Juvenile Form – 10 Page 2 of 2 REQUEST FOR SERVICE Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • IN THE COURT OF COMMON PLEAS Division COUNTY, OHIO IN THE MATTER OF: A Minor : Plaintiff/Petitioner : Case No. : Street Address : : Judge City, State and Zip : : vs. : Magistrate : : Defendant/Respondent/Petitioner : : Street Address : : City, State and Zip Code : :

    WAIVER OF SERVICE OF SUMMONS I, (name), acknowledge that I am the Petitioner Plaintiff

    Defendant Respondent (select one) and that I have received a copy of the following documents filed or to be filed by the other party: Complaint for Parentage Complaint Motion (select one) for Allocation of Parental Rights and Responsibilities (Custody) Complaint Motion (select one) for Parenting Time (Companionship and Visitation) Complaint Motion (select one) for Establishment or Change of Child Support Journal Entry and Findings of Fact Supporting Child Support Deviation Health Insurance Affidavit Complaint for Divorce with Children Complaint for Divorce without Children Separation Agreement Shared Parenting Plan Parenting Plan Petition for Dissolution Agreed Judgment Entry, Magistrate’s Decision, Order, and/or Magistrate’s Order Affidavit of Income and Expenses Supreme Court of Ohio Uniform Domestic Relations Form – 27 Uniform Juvenile Form – 9 WAIVER OF SERVICE OF SUMMONS Page 1 of 2 Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • Affidavit of Property Parenting Proceeding Affidavit Motion for Contempt and Affidavit Motion and Affidavit or Counter Affidavit for Temporary Orders with Oral Hearing Other (specify): I waive service of summons of said document by the Clerk of Court.

    Date Your Signature Telephone number at which the Court may reach you

    or at which messages may be left for you

    Supreme Court of Ohio Uniform Domestic Relations Form – 27 Uniform Juvenile Form – 9 WAIVER OF SERVICE OF SUMMONS Page 2 of 2 Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Effective Date: 7/1/2013

  • IN THE COURT OF COMMON PLEAS, SCIOTO COUNTY, OHIO DOMESTIC RELATIONS DIVISION

    Case No.

    Plaintiff, JUDGE BUCKLER

    vs. Magistrate Jones

    AFFIDAVIT FOR SERVICE PURSUANT TO O.R.C. 4.4(A)(2)

    Defendant. I, being first duly sworn and cautioned, depose and state as follows:

    1. I have filed a Motion for Change of Custody and am not able to prepay the filing fees;

    2. I do not know the current address of the plaintiff/defendant (circle one);

    3. I have made efforts to determine the plaintiff’s/defendant’s (circle one) current address

    but have been unable to do so;

    4. The plaintiff’s/defendant’s (circle one) residence cannot be learned with reasonable effort

    5. The plaintiff’s/defendant’s (circle one) last known mailing address is:

    Affiant

    STATE OF OHIO, COUNTY OF , SS:

    Sworn to before me and signed in my presence this day of __________________,20 .

    ______________________________________

  • CHANGE OF CUSTODY FACT SHEET

    A court cannot change custody from you to the other parent unless certain requirements of Ohiolaw, Revised Code Section 3109.04, are met. The court must review certain facts in decidingwhether to change custody.

    The court must decide if there has been a “change of circumstances” of the child or thecustodial parent (or a parent in shared parenting plan). The change of circumstance must haveoccurred after the last custody decree. (Issues the court has heard and decided cannot be raisedagain.) Such issues might include the mental instability of the custodial parent, frequent changes ofresidence, abuse or neglect of the child or his education or substance abuse. Other issues may beconsidered. However, the situation must have a direct, adverse impact on the child. Frequently, aparent seeking custody will try to combine a series of minor events or situations to show that therehas been a detrimental change is circumstance.

    Once the court finds that a “change of circumstances” has occurred, the court must determine if: a) the present custodian has agreed to the change of custody; b) the child has been placed in the other parent’s home by the custodial parent and is

    integrated into that home; or c) the harm likely to be caused by such a change of environment is outweighed by the

    benefit of placing the child in the other home.

    Ohio law creates a presumption in favor of retaining the present custodian; however, sufficientevidence can rebut this presumption. The court must consider the following factors in deciding whatis in the child’s “best interest”:

    1) the wishes of each parent; 2) the wishes and concerns of the child; 3) the child’s interaction with the parents, siblings, and other people who impact the

    child (neighbors, friends, teachers); 4) the child’s adjustment to the home, school and community; 5) the mental and physical health of all persons involved; 6) the parent most likely to honor and facilitate visitation; 7) whether a parent has failed to make ongoing child support payments; 8) whether the custodial parent has willfully denied visitation to the other parent; 9) whether either parent is planning to establish a residence out of state; and 10) whether either parent has abused children or been a perpetrator of domestic

    violence.

    Any child who is mature may state an opinion as to who should be the legal custodian. Thechild’s wishes are one of many factors in deciding what is in the child’s “best interest.” The court ispermitted by statute to interview a child in chambers (privately) if either parent requests such aninterview.

    You may ask the court to appoint a guardian ad litem (GAL). A GAL will investigate andreport to the court. The GAL will talk with parents, teachers, counselors and others and reviewrecords. The GAL also will talk with the child. You should cooperate with the guardian ad litemwho has been appointed on the case. You should provide the names and telephone numbers for yourchild's teachers (last year and this), counselors, pediatrician, and others who may have knowledge ofyour child's needs and environment.

    P:\7-Publications\pamphlets2\CHANGE OF CUSTODY FACT SHEET-2.wpd

  • Representing

    Yourself in Court?

    How to Use Photographs,

    Letters, Business Records,

    and Other Evidence to Help

    Prove Your Case

    What is Evidence?

    Evidence is anything you use to prove your claim. Evidence can be a photograph, a letter,

    documents or records from a business, and a variety of other things. All evidence that is

    properly admitted will be considered by the judge.

    Your case probably will be decided by a judge. If there is a jury, it will look at admitted

    exhibits during its deliberations.

    For example:

    • In a request for change of custody, the child’s school records could be introduced as

    evidence that the child’s grades have dropped or he/she has missed a significant amount of

    school while living with the other parent.

    • In a domestic violence or stalking civil protection order case, a photograph of any

    injury you suffered or a threatening letter written by your abuser may help your case.

    • In a divorce case, a copy of tax return documents or documents showing who has title to

    a car may be introduced as evidence.

  • Exhibit 1

    Why Use Evidence?

    Ø Evidence is more believable and trustworthy than what a person says. For example, in a

    domestic violence case, if you say that your ex-boyfriend has left you threatening messages

    but he testifies that this is an absolute lie, the judge may not know whom to believe.

    However, if you submit a tape recording of one of these messages the judge will be more

    likely to believe you.

    Ù Evidence may make something easier to understand. “A picture is worth a thousand

    words.” Some things are hard to explain in words, while a drawing or photograph is

    descriptive and clear.

    How Do I Present Evidence to the Court?

    Each court is different, but in most courts, you can’t just walk into court with a photograph or

    document and show it to the judge or jury. There are many things you must do before the court

    will even look at the evidence you have. Further, there are many different types of evidence, and

    the rules for using each type of evidence are different. Once you follow these rules, your

    evidence will be “admitted”.

    Steps to Follow to Admit Evidence

    º Before you ever go to court, think about the evidence you want to use to

    prove your case. Mark each piece of evidence with an exhibit number

    (attach a sticker labeled “Exhibit 1,” “Exhibit 2,” etc.)

    º Bring these marked Exhibits with you to court. When you want to show

    the court one of the exhibits, do the following things:

    ì Show the exhibit to the other party or the other party’s attorney.

    í Then “lay the foundation” for the evidence. To do this, you must show that the

    evidence is relevant to your case and authentic (not a forgery). Depending upon

    what you want the court to consider, follow the rules listed in this pamphlet for

    “laying the foundation” - explaining why and how the exhibit is connected to your

    case.

    Ú Either you or your witness must testify about the exhibit.

    Û Ask the court to admit the exhibit into evidence. The other party or attorney may

    object to the exhibit for some reason. Try to answer these objections as best you

    can. If you can’t, let the judge decide.

    Ü If there are no objections from the other party, or the judge has ruled in your favor,

    ask the court to “admit the Exhibit into evidence.”

  • Laying the Foundation for Photographs

    1. Explain why a photo is connected to your case. For example:

    “This photo shows the injury I suffered after my ex-boyfriend punched andkicked me.”

    2. Explain how you know about what is in the photo. For example:

    “I had my sister take this photograph within 2 hours after theincident occurred and went to get the film developed myselfthe following day.”

    3. Explain that the photo is timely. For example:

    “At the bottom right-hand corner of the photo is the date on which it was taken. As you can see, the photo was taken on the sameday that the incident occurred, which is also thesame day the police arrested my ex-boyfriend.”

    4. Explain that the photo “fairly and accurately” shows what

    is depicted in the photo as it appeared on the date relevant

    to your case. For example:

    “This photo is a fair and accurate depiction ofhow my face and side looked two hours afterthe incident and for the next two weeks.”

    Foundation for Letters

    1. Explain why the letter is connected to your case. For example:

    “This is the letter that I received from my ex-boyfriend shortlybefore he beat me up."

    2. Explain when and how you got the letter. For example:

    “This letter was shoved under the door to my apartmentsome time before 6 p.m. on Wednesday, January 2, 2001. I found it on the floor when I came home from work thatday.”

    3. Prove that the signature is that of a party to the case. Ways to prove this:

    • Explain to the court: that you are familiar with the other party’s signature, how

    you came to know that person’s signature, and that it is your opinion that the

    signature on the letter is the other party’s signature.

    TIPWhen using photographs, it is

    best to use color photos and

    enlarge them, if possible.

  • • Call a witness who is familiar with the party’s signature, and ask the witness:

    “Do you know the other party in this case? Are you familiar with the party’ssignature? How?”

    Then show them the letter and ask “Is thisthe other party’s signature?”

    • Call the person who signed the letter.Show the witness the document, and ask

    the witness if that is his or her signature.

    (Only do this if you think they will admit to

    it).

    4. Explain that the letter is in the same condition

    now as when you received it. (“The letter waskept in a safe place and nothing has been changed since I received it.”)

    Laying the Foundation for Documents and Records

    From Businesses

    1. Explain how the document or record is related to your case.

    2. Call a witness from the business/agency that produced the record, ask

    the witness what his or her responsibilities are at the business/agency

    and how he or she is involved in record keeping.

    3. Show the witness the record and ask him/her if it is a record from the business/agency.

    4. Ask the witness:

    • Was the record made by a person with

    knowledge of the acts or events appearing on

    it.

    • Was the record made at or near the time of the

    acts or events appearing on it.

    • Is it the regular practice of the business/agency

    to make such a record, and

    • Was the record kept in the course of a

    regularly conducted business activity.

    Created by: NAPIL Equal Justice Fellow, Ohio State Legal Services Association®

    © 1/2001 OSLSA

    TIPSDo not read anything from the letter

    until the court has admitted it into

    evidence.

    If the other party objects to the letter

    saying that it is hearsay, respond by

    saying: “The letter shows the letter

    writer’s state of mind.”

    TIPIf the record is certified (a statement is

    attached to the record stating that it is

    in fact a record from a public agency

    or it has an agency seal on it) you do

    not need to do anything before you

    show it to the judge. Just let the judge

    know it is certified.

  • In addition to the forms in this packet, you may find additional forms and informational pamphlets to help you on the internet at the

    following website:

    www.ohiolegalhelp.org

    Click on “Statewide Forms and Information”

    Locate and click on the legal area that you would like to review – use the “search this site” box if you are not sure which area to

    review

    You can also search this website to learn how to access the local legal services

    program for your area

    Motion for Change of Custody - no agreement - SciotoCOUNTY, OHIOSECTION I - INCOMEA. YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARSB. COMPUTATION OF CURRENT INCOMETOTAL MONTHLY TOTAL MONTHLY TOTAL MONTHLYType of LiabilityAmountRent / MortgageCable

    PETITION FOR WAIVER OFWAIVER OF SERVICE OF SUMMONS

    Judicial College Citizen Guide to Representing Yourself in CourtCourt Hearing on Change of CustodyCHANGE OF CUSTODY FACT SHEETHow to Handle WitnessesRepresenting Yourself in Court - documentsWebsite Information

    NOTE If you did not complete the poverty affidavit the filing fee is: Style: undefined: DR Divorce: 1: 2: DM Dissolution: 1_2: 2_2: DV Domestic Violence: DO Other Domestic Relations Matters: 1_3: 2_3: 3: 4: 5: 6: K 1: K 2: K 3: K 4: IN THE COURT OF COMMON PLEAS: COUNTY OHIO: IN THE MATTER OF: undefined_2: Name: Case No: Street Address: Judge: Magistrate: undefined_3: Name_2: Street Address_2: AND MEMORANDUM IN SUPPORT: name request this Court change the allocation of: parental rights and responsibilities custody Order filed on this date: Name of Child 1: Name of Child 2: Name of Child 3: Date of Birth 1: Date of Birth 2: Date of Birth 3: parent andor legal custodian of the children and resides in the: name is currently designated as the residential: The parents now have a Shared Parenting Plan: Offcircumstances and any other reason for the requested change are as follows 1: circumstances and any other reason for the requested change are as follows 2: circumstances and any other reason for the requested change are as follows 3: I request that the Court change the existing order in the following way 1: I request that the Court change the existing order in the following way 2: I request that the Court change the existing order in the following way 3: undefined_4: Check Box1: OffDivision: COUNTY OHIO_2: A Minor: undefined_5: Case No_2: undefined_6: undefined_7: Judge_2: Magistrate_2: undefined_8: undefined_9: undefined_10: name request this Court change my obligation to: The amount of child support to be paid each month The change I want the Court to order is: Off1_4: 2_4: 2_5: OffThe person responsible for providing health insurance for the children The change I want the: Court to order is 1: Court to order is 2: 3_2: OffThe amount of noninsured health care expenses of the minor children that I have to pay: The change I want the Court to order is 1: The change I want the Court to order is 2: 4_2: OffThe person who can claim the children as tax dependents The change I want the Court to: order is 1: order is 2: 5_2: Offundefined_11: Other childrelated expenses The change I want the Court to order is 1: Other childrelated expenses The change I want the Court to order is 2: The circumstances have changed since the Court issued the existing order The change in: circumstances and any other reason for the requested change are as follows 1_2: circumstances and any other reason for the requested change are as follows 2_2: circumstances and any other reason for the requested change are as follows 3_2: undefined_12: COUNTY OHIO_3: PlaintiffPetitioner: Case No_3: Judge_3: Magistrate_3: DefendantPetitioner: Affidavit of: Date of marriage: Date of separation: undefined_13: No1_5: 2_6: 3_3: 1_6: 2_7: 3_4: 12: Off24: Off26: Off52: Off12_2: Off24_2: Off26_2: Off52_2: Off20: undefined_14: undefined_15: undefined_16: 20_2: undefined_17: undefined_18: 20_3: undefined_19: undefined_20: 20_4: undefined_21: undefined_22: 20_5: undefined_23: undefined_24: 20_6: undefined_25: undefined_26: undefined_27: Check Box3: OffWorkers Compensation: OffSocial Security: OffOther: Offundefined_28: Social Security_2: OffOther_2: Offundefined_29: source 1: source 2: Other income type and source 1: Other income type and source 2: undefined_30: undefined_31: undefined_32: undefined_33: undefined_34: undefined_35: undefined_36: undefined_37: undefined_38: undefined_39: undefined_40: undefined_41: undefined_42: undefined_43: undefined_44: undefined_45: undefined_46: undefined_47: undefined_48: undefined_49: Name_3: Date of birth: Living with: 1_7: 2_8: 3_5: 4_3: 1_8: 2_9: 3_6: 4_4: 1_9: 2_10: 3_7: 4_5: adults: other minor andor dependent children: undefined_50: undefined_51: undefined_52: undefined_53: undefined_54: undefined_55: undefined_56: undefined_57: undefined_58: undefined_59: undefined_60: undefined_61: Other 1: Other 2: undefined_62: undefined_63: undefined_64: undefined_65: undefined_66: undefined_67: undefined_68: undefined_69: undefined_70: undefined_71: undefined_72: undefined_73: Other_3: undefined_74: undefined_75: undefined_76: Other_4: undefined_77: undefined_78: undefined_79: undefined_80: undefined_81: undefined_82: undefined_83: undefined_84: undefined_85: undefined_86: undefined_87: Other_5: undefined_88: undefined_89: undefined_90: undefined_91: undefined_92: undefined_93: undefined_94: Other_6: undefined_95: undefined_96: undefined_97: undefined_98: undefined_99: undefined_100: undefined_101: Other 1_2: Other 2_2: undefined_102: undefined_103: undefined_104: undefined_105: undefined_106: undefined_107: Other 1_3: Other 2_3: undefined_108: undefined_109: undefined_110: undefined_111: undefined_112: undefined_113: undefined_114: undefined_115: undefined_116: undefined_117: undefined_118: undefined_119: undefined_120: undefined_121: undefined_122: undefined_123: type: undefined_124: Additional taxes paid not deducted from wages type: undefined_125: Other 1_4: Other 2_4: undefined_126: undefined_127: undefined_128: To whom paid 1: To whom paid 2: To whom paid 3: To whom paid 4: To whom paid 5: To whom paid 6: To whom paid 7: To whom paid 8: To whom paid 9: To whom paid 10: To whom paid 11: To whom paid 12: To whom paid 13: To whom paid 14: To whom paid 15: Purpose 1: Purpose 2: Purpose 3: Purpose 4: Purpose 5: Purpose 6: Purpose 7: Purpose 8: Purpose 9: Purpose 10: Purpose 11: Purpose 12: Purpose 13: Purpose 14: Purpose 15: undefined_129: undefined_130: undefined_131: undefined_132: undefined_133: undefined_134: undefined_135: undefined_136: undefined_137: undefined_138: undefined_139: undefined_140: undefined_141: undefined_142: undefined_143: undefined_144: undefined_145: undefined_146: undefined_147: undefined_148: undefined_149: undefined_150: undefined_151: undefined_152: undefined_153: undefined_154: undefined_155: undefined_156: undefined_157: undefined_158: undefined_159: undefined_160: this document and to the best of my knowledge and belief the facts and information stated in this document: day of: undefined_161: undefined_162: Notary Public: My Commission Expires: COUNTY OHIO_4: PlaintiffPetitioner_2: 1_10: 2_11: Magistrate_4: DefendantPetitionerRespondent: Affidavit of_2: Childs Name: Place of Birth: Date of Birth: Persons With Whom Child Lived: OffMale: Offundefined_163: Confidential: OffAddress 1: Address 2: undefined_164: undefined_165: undefined_166: Confidential_2: OffAddress 1_2: Address 2_2: undefined_167: undefined_168: undefined_169: Confidential_3: OffAddress 1_3: Address 2_3: undefined_170: undefined_171: undefined_172: Confidential_4: OffAddress 1_4: Address 2_4: undefined_173: Check Box5: OffCheck Box6: OffChilds Name_2: Place of Birth_2: Date of Birth_2: Check this box if the information requested below would be the same as in subsection 2a and skip to the next question: Offundefined_174: Address: Offundefined_175: undefined_176: Address_2: OffConfidential_5: undefined_177: undefined_178: Address_3: OffConfidential_6: undefined_179: undefined_180: Address_4: OffConfidential_7: name address 1: name address 2: name address 3: name address 4: name address 5: name address 6: name address 7: name address 8: undefined_181: Childs Name_3: Place of Birth_3: Date of Birth_3: Sex_2: OffCheck this box if the information requested below would be the same as in subsection 2a and skip to the next question_2: Offundefined_182: Address_5: Offundefined_183: undefined_184: Confidential_8: Address_6: Offundefined_185: undefined_186: Address_7: OffConfidential_9: undefined_187: undefined_188: Address_8: OffConfidential_10: 1_11: 2_12: 3_8: 4_6: 5_3: 6_2: 7: 8: undefined_189: undefined_190: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffName of each child: 1_12: 2_13: 1_13: 2_14: Type of case: Court and State: undefined_191: Date and court order or judgment if any: undefined_192: Offneglect or abuse allegations or adoptions concerning a child subject to this case Do not repeat: cases already listed in Paragraph 3 Explain: Name of each child_2: undefined_193: undefined_194: Type of case_2: Court and State_2: undefined_195: Date and court order or judgment if any_2: undefined_196: OffName 1: Name 2: Name 3: Name 4: Case Number 1: Case Number 2: Case Number 3: Case Number 4: CourtStateCounty 1: CourtStateCounty 2: CourtStateCounty 3: CourtStateCounty 4: What Crime 1: What Crime 2: What Crime 3: What Crime 4: undefined_197: OffCheck Box11: OffCheck Box12: OffI DO NOT KNOW OF ANY PERSONS not a party to this case who hashave physical custody or: OffI KNOW THAT THE FOLLOWING NAMED PERSONS not a party to this case hashave physical: Offcustody or claims to have custody or visitation rights with respect to any child subject to this case: undefined_198: Has physical custody: OffClaims custody rights: OffClaims visitation rights: OffName of each child_3: 1_14: 2_15: 1_15: 2_16: NameAddress of Person: undefined_199: Has physical custody_2: OffClaims custody rights_2: OffClaims visitation rights_2: OffName of each child_4: 1_16: 2_17: NameAddress of Person_2: 1_17: 2_18: Has physical custody_3: OffClaims custody rights_3: OffClaims visitation rights_3: OffName of each child_5: 1_18: 2_19: 1_19: 2_20: this document and to the best of my knowledge and belief the facts and information stated in this document_2: day of_2: undefined_200: undefined_201: Notary Public_2: My Commission Expires_2: County CSEA Child Support Enforcement Agency I understand and agree to the following: Date of Birth_4: 1_20: 2_21: 3_9: 4_7: 5_4: 1_21: 2_22: 3_10: 4_8: 5_5: 6_3: Married: OffSeparated: OffSingle: OffDivorced: Off1_22: 2_23: 3_11: 4_9: 5_6: 6_4: 1_23: 2_24: 3_12: 4_10: Employer Phone: undefined_202: 1_24: 2_25: 3_13: undefined_203: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text53: Text54: Text55: Text56: Text57: Text58: Text59: Text60: Text91: Text92: Text93: Text94: Text95: Text20: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text61: Text62: Text63: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: Text73: Text74: Text75: Text76: Text77: Text78: Text79: Text96: Text97: Text98: Text99: Text100: Text101: Text102: Text103: Text104: Text105: Text106: Text107: Text108: Text109: Text110: Text111: Text112: Text113: Text114: fill_6: fill_7: fill_8: Per: Per_2: Per_3: Date: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Text48: Text49: Check Box50: OffCheck Box51: OffCheck Box52: OffText80: Text81: Text82: Text83: Text84: Text85: Text86: Text87: Text88: Text89: Text90: Text115: Text116: Text117: Text118: Text119: Text120: Text121: Text122: Text123: Text124: 1_25: 2_26: 3_14: undefined_206: 1_26: 2_27: 3_15: undefined_207: CASE NUMBER: Please mark one of the following boxes and fill in the appropriate information: Offcase: Or: Offthe Petitioners in the abovecaptioned case: are: PlaintiffPetitioner_3: DefendantPetitioner_2: being duly sworn sayeth: Affiant: Sworn before me and subscribed in my presence this: 20_7: undefined_208: Notary public or Deputy Clerk: NameApplicant: Party Represented if applicant enter same DOB: Mailing Address: City: State: Zip: Case No_4: Phone: Name 1_2: Name 3_2: DOB2: Relationship2: DOB4: Relationship4: ApplicantEmployment Gross: Spouse or Parents if application is a juvenileEmployment Gross: Other Household MembersEmployment Gross: TotalEmployment Gross: ApplicantUnemployment: Spouse or Parents if application is a juvenileUnemployment: Other Household MembersUnemployment: TotalUnemployment: ApplicantWorkers Comp: Spouse or Parents if application is a juvenileWorkers Comp: Other Household MembersWorkers Comp: TotalWorkers Comp: ApplicantPensionSocial Security: Spouse or Parents if application is a juvenilePensionSocial Security: Other Household MembersPensionSocial Security: TotalPensionSocial Security: ApplicantChild Support: Spouse or Parents if application is a juvenileChild Support: Other Household MembersChild Support: TotalChild Support: ApplicantWorks FirstTANF: Spouse or Parents if application is a juvenileWorks FirstTANF: Other Household MembersWorks FirstTANF: TotalWorks FirstTANF: ApplicantDisability: Spouse or Parents if application is a juvenileDisability: Other Household MembersDisability: TotalDisability: ApplicantOther: Spouse or Parents if application is a juvenileOther: Other Household MembersOther: TotalOther: Employers Name for all household members: fill_62: Phone_2: AmountChild Support Paid Out: AmountChild Care if working only: AmountTransportation for work: AmountInsurance: fill_77: AmountMedical Dental: fill_79: AmountMedical Associated Costs of Caring for Infirm Family members: fill_80: fill_82: Estimated ValuePrice Date Purchased Amt Owed: Price Date Purchased Amt Owed StocksBondsCDs: Estimated ValueStocksBondsCDs: Price Date Purchased Amt Owed Automobiles: Estimated ValueAutomobiles: Price Date Purchased Amt Owed TrucksBoatsMotorcycles: Estimated ValueTrucksBoatsMotorcycles: Price Date Purchased Amt Owed Other Valuable Property: Estimated ValueOther Valuable Property: Price Date Purchased Amt Owed Cash on Hand: Estimated ValueCash on Hand: Price Date Purchased Amt Owed Money Owed to Applicant: Estimated ValueMoney Owed to Applicant: Price Date Purchased Amt Owed Other: Estimated ValueOther: Price Date Purchased Amt Owed Checking Acct BankAcct: Estimated ValueChecking Acct BankAcct: Price Date Purchased Amt Owed SavingsMM Acct BankAcct: Estimated ValueSavingsMM Acct BankAcct: fill_85: Text125: Text126: Text127: Text131: Text132: Text133: Text134: AmountRent Mortgage: AmountFood: undefined_209: AmountElectric: AmountGas: undefined_210: AmountFuel: AmountTelephone: E LIABILITIES OTHER: AmountCable: AmountWater Sewer Trash: AmountCredit Cards: AmountLoans: AmountTaxes Owed: AmountOther: AmountE LIABILITIES OTHER EXPENSE: affiant being duly sworn say: Date_2: day of_3: Subscribed and duly sworn before me according to law by the above named applicant this: and State of: undefined_211: undefined_212: County of: Title: undefined_213: Date_3: Division_2: COUNTY OHIO_5: A Minor_2: Name_4: Case No_5: Street Address_3: Judge_4: City State and Zip Code: Magistrate_5: Name_5: Street Address_4: City State and Zip Code_2: Please serve the following documents on the following parties as I have indicated below 1: Please serve the following documents on the following parties as I have indicated below 2: DefendantPetitioner at the address shown above: OffCertified Mail Return Receipt Requested: OffIssuance to Sheriff of: OffOther specify: OffCounty Ohio for: Personal or: OffResidence service: Offundefined_214: PlaintiffPetitioner at the address shown above: OffCertified Mail Return Receipt Requested_2: OffIssuance to Sheriff of_2: OffOther specify_2: Offundefined_215: Personal or_2: OffResidence service_2: OffCounty Ohio for_2: undefined_217: County Child Support Enforcement Agency provide address below: Certified Mail Return Receipt Requested_3: OffIssuance to Sheriff of_3: OffOther specify_3: Offundefined_218: Personal or_3: OffResidence service_3: OffCounty Ohio for_3: Other address: Offundefined_219: Certified Mail Return Receipt Requested_4: OffIssuance to Sheriff of_4: OffOther specify_4: Offundefined_220: Personal or_4: OffResidence service_4: OffCounty Ohio for_4: SPECIAL INSTRUCTIONS TO SHERIFF 1: SPECIAL INSTRUCTIONS TO SHERIFF 2: SPECIAL INSTRUCTIONS TO SHERIFF 3: Check Box135: OffDivision_3: COUNTY OHIO_6: A Minor_3: undefined_221: Case No_6: undefined_222: undefined_223: Judge_5: Magistrate_6: undefined_224: undefined_225: undefined_226: name acknowledge that I am the: Petitioner: OffPlaintiff: OffDefendant: OffRespondent select one and that I have received a copy of the following documents filed or: OffComplaint for Parentage: OffComplaint: OffComplaint_2: OffComplaint_3: OffJournal Entry and Findings of Fact Supporting Child Support Deviation: OffHealth Insurance Affidavit: OffComplaint for Divorce with Children: OffComplaint for Divorce without Children: OffSeparation Agreement: OffShared Parenting Plan: OffParenting Plan: OffPetition for Dissolution: OffAgreed Judgment Entry Magistrates Decision Order andor Magistrates Order: OffAffidavit of Income and Expenses_2: OffMotion select one for Allocation of Parental Rights and Responsibilities Custody: OffMotion select one for Parenting Time Companionship and Visitation: OffMotion select one for Establishment or Change of Child Support: OffAffidavit of Property: OffParenting Proceeding Affidavit_2: OffMotion for Contempt and Affidavit: OffMotion and Affidavit or Counter Affidavit for Temporary Orders with Oral Hearing: OffOther specify_5: Offundefined_227: I waive service of summons of said document by the Clerk of Court: undefined_228: undefined_229: Case No_7: undefined_230: I: The plaintiffsdefendants circle one last known mailing address is 1: The plaintiffsdefendants circle one last known mailing address is 2: The plaintiffsdefendants circle one last known mailing address is 3: Affiant_2: STATE OF OHIO COUNTY OF: Sworn to before me and signed in my presence this: day of_4: undefined_231: