5101:12-60-99 Chapter 5101:12-60 forms - order administration.

Rule Summary and Fiscal Analysis (Part A)

Department of Job and Family Services

Agency Name

Child Support Michael Lynch

Division Contact

OFC- 4200 E. 5th Ave., 2nd fl. J6-02 P.O. Box 183204 Columbus OH 43218-3204

614-466-4605 614-752-8298

Agency Mailing Address (Plus Zip) Phone Fax

Michael.Lynch@jfs.ohio.gov

5101:12-60-99

Rule Number

AMENDMENT

TYPE of rule filing

Rule Title/Tag Line Chapter 60 forms - order administration.

RULE SUMMARY

1. Is the rule being filed for five year review (FYR)? No

2. Are you proposing this rule as a result of recent legislation? No

3. Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4. Statute(s) authorizing agency to adopt the rule: 3125.25

5. Statute(s) the rule, as filed, amplifies or implements: 3125.03, 3125.25

6. State the reason(s) for proposing (i.e., why are you filing,) this rule:

This rule is being proposed to update the revisions dates of some the referenced forms.

7. If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

Page 2 Rule Number: 5101:12-60-99

This rule contains a compilation of forms with their effective or revised effective date, referenced within various rules contained within division 5101:12 of the Administrative Code, but first cited within Chapter 5101:12-60 of the Administrative Code. The rule is being revised to list two new forms JFS 00592 and JFS 00593, and to update the revision dates of other forms.

8. If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This rule incorporates one or more dated references to an ODJFS form or forms. Each cited ODJFS form is dated and is generally available to persons affected by this rule via the "Info Center" link on the ODJFS web site (http://jfs.ohio.gov//) in accordance with ORC 121.75(E).

This rule incorporates one or more references to another rule or rules of the Ohio Administrative Code (OAC). This question is not applicable to any incorporation by reference to another OAC rule because such reference is exempt from compliance with ORC 121.71 to 121.74 pursuant to ORC 121.76(A)(3).

9. If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

Not Applicable.

10. If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11. If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:

Not Applicable.

Page 3 Rule Number: 5101:12-60-99

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13. Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures.

No impact on current budget.

14. Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

N/A.

15. Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

No new costs.

16. Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17. Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No

S.B. 2 (129th General Assembly) Questions

Page 4 Rule Number: 5101:12-60-99

R.C. 121.82? No

19. Specific to this rule, answer the following:

A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No

B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? No

C.) Does this rule require specific expenditures or the report of information as a condition of compliance? No

<County Name> County CSEA	Telephone Number:	<CSEA Local phone #>
<CSEA Address 1>	Toll Free Number:	<CSEA 800 #>
<CSEA Address 2>	Fax Number:	<CSEA Fax #>
<CSEA City, State, ZIP>

<1st copy to obligor's and 2nd copy to obligee's first and last names>

<City, State, and Zip>

		Date:	<print date>
Case Number:	<SETS number>	Child Support Obligor:	<Obligor's name>
Order Number:	<order number>	Child Support Obligee:	<Obligee's name>

Ohio Department of Job and Family Services

ADMINISTRATIVE ADJUSTMENT RECOMMENDATION

(Ohio Revised Code 3119.60 through 3119.71)

On <Date of Review> the <County> CSEA conducted an administrative review of the support obligations for the child(ren) listed below.

CHILD'S NAME CHILD'S DATE OF BIRTH

<child' first and last names> <child's DOB>

	PRESENT ORDER	RECOMMENDED ORDER EFFECTIVE <Date Certain>
Current Support Order When Cash Medical is Not Ordered	$<Current Obligation> per month
Current Support When Private Health Insurance is Provided	$<Current Obligation> per month	$<Recommended Obligation> per month
Current Support When Private Health Insurance is Not Provided	$<Current Obligation> per month	$<Recommended Obligation> per month
Cash Medical Support	$<Current Obligation> per month	$<Recommended Obligation> per month
Parent(s) Ordered to Provide Private Health Insurance	<Ordered Parent(s) name>	<Ordered Parent(s) name>
Division of Health Care Costs	<Current %> Obligor <Current %> Obligee	<Recommended %> Obligor <Recommended %> Obligee
Payment on Arrears (Past due support)	$<Current Obligation> per month	$<Recommended Obligation> per month

JFS 07724 (Rev. 2/2015) Page 1 of 5

RECOMMENDATIONS

The effective date of this support order is <Date Certain>. The CSEA completed a Guidelines Worksheet, a copy of which is attached, and recommends the following (only the checked boxes apply):

That <Obligor's first and last names> pay:

$<monthly child support obligation when health insurance is provided> per month plus 2% processing charge for current child support when private health insurance is being provided in accordance with the support order. This child support obligation becomes effective on the first day of the month in which private health insurance coverage for the child(ren) is provided in accordance with the order.

$<monthly child support obligation when health insurance is not provided> per month plus 2% processing charge for current child support when private health insurance is not being provided in accordance with the support order. This child support obligation becomes effective on the first day of the month in which private health insurance coverage for the child(ren) is provided in accordance with the order is unavailable or terminates.

$<monthly cash medical support obligation> per month plus 2% processing charge for cash medical support when private health insurance is not being provided in accordance with the support order. This cash medical support obligation becomes effective on the first day of the month following the month in which private health insurance coverage for the child that is provided in accordance with the order is unavailable or terminates.

The child support order should not be adjusted at this time as the calculated amount does not represent a change of more than 10% from the current support obligation.

That <Health Insurance Obligor/Obligors Name(s)> is able to provide private health insurance coverage for the child(ren) named above that is accessible and reasonable in cost through a group policy, contract, or plan, and should be the Health Insurance Obligor(s) and provide health insurance coverage for the child(ren) named above.

The costs of private health insurance exceed the health insurance maximum indicated on line 7b of the Child Support Guidelines Computation Worksheet and: (a) both parents have agreed that one or both of the parents obtain or maintain the private health insurance that exceeds five per cent of the annual gross income of the parent obtaining or maintaining the private health insurance; or (b) either parent has requested to obtain or maintain the private health insurance that exceeds five per cent of that parent's annual gross income.

That private health insurance coverage is not accessible or reasonable in cost through a group policy, contract, or plan available to the obligor or obligee at the time of the issuance of this findings and recommendations. Therefore, in accordance with ORC section 3119.30 (B)(4), if private health insurance coverage for the child(ren) named above becomes available through any group policy, contract, or plan available to the obligor or obligee, the obligor or obligee to whom the coverage becomes available immediately inform the CSEA of the available coverage. If the CSEA determines that the private health insurance coverage is accessible and reasonable in cost, the CSEA will notify both parties that the person to whom the coverage is available is now the Health Insurance Obligor and is ordered to secure and maintain private health insurance for the child(ren) named above.

That <Father's first and last names> pay <percentage>% and <Mother's first and last names> should pay

<percentage>% of the costs of the health care needs of the child(ren) named above that exceed the amount of cash medical support ordered to be paid, if any, when private health insurance coverage is not available or is not being provided in accordance with the support order, OR of the uninsured health care costs or co- payment or deductible costs required under the health insurance policy, contract, or plan that covers the child(ren) named above, when private health insurance coverage is being provided in accordance with the support order.

That obligor pay $<total of all monthly arrears/balance payments> per month as payment on arrears (past due support) or other balances

That both parties immediately inform the court, when the support order is a court support order, or the CSEA, when the support order is an administrative child support order, of any available private health insurance coverage for the child(ren) named above.

That if private health insurance coverage for the child(ren) named above becomes available through any group policy, contract, or plan available to the obligor or obligee, the obligor or obligee to whom the coverage becomes available immediately inform the CSEA of the available coverage.

Additional findings or recommendations are attached

Any other orders not expressly modified herein are to remain in full force and effect.

In accordance with paragraph (I) of ORC section 3119.32, upon receipt by the CSEA of notice that private health insurance coverage that is reasonable in cost is not available to the health insurance obligor, cash medical support will be ordered to be paid in the amount identified in the current support order. The CSEA may change the financial obligation of the parties to pay child support and cash medical support without a hearing or additional notice to the parties.

Your Right to an Administrative Adjustment Hearing

This order is a Judicial (Court) Order Administrative Order

You have the right to request an administrative adjustment hearing if you disagree with the recommendations. The procedure and time frame for requesting an administrative adjustment hearing is described below.

A request for an administrative adjustment hearing must be received timely.

• When the order is an ADMINISTRATIVE order, you must request the hearing within thirty (30) calendar days plus

(3) business days of the date that this notice was mailed.

• When the order is a JUDICIAL order, you must request the hearing within fourteen (14) calendar days plus (3) business days of the date that this notice was mailed.

You will be notified of the date of the administrative adjustment hearing by regular mail. The CSEA can permit one request for postponement of the hearing if the CSEA determines that you have a valid reason that prevents you from attending the hearing. Your request for a postponement must be received by the CSEA at least seven (7) days before the scheduled hearing date. You may bring legal counsel or a representative to the hearing.

Please be advised that a request for a hearing will not change the effective date of the revised order.

The CSEA is not allowed to deviate from Ohio Child Support Guidelines. If either party intends to request a deviation, the party has a right to request a court hearing without first requesting an administrative adjustment hearing. In order to exercise this right, the request for a court hearing must be made no later than fourteen (14) days plus three (3) business days of the date of the issuance of the administrative review recommendation.

To request an administrative adjustment hearing on this recommendation, you must complete the final page of this form and submit it to the <County Name> County CSEA.

If neither party submits a timely request for a hearing, a new support order will be issued that incorporates these recommendations.

<Worker's Name> Authorized Representative

Request for an Administrative Adjustment Hearing

In order to request an administrative adjustment hearing, please complete the form below and mail it to the address of the CSEA listed on the front page of this Notice.

I am requesting an administrative adjustment hearing for the reason(s) listed below:

I am electing to skip the administrative adjustment hearing and request a court hearing to address a deviation from the Ohio Child Support Guidelines.

Print Name: Address:

Case Number: <SETS #> Order Number: <order #>

Home Phone:

Cell Phone:

Email:

Signature:

Date:

ACTION: To Be Refiled DATE: 10/09/2014 1:35 PM

<County CSEA Name> Phone: <CSEALocalPhone#>

<CSEACity,State,Zip>

<RequestingPartyFirst&LastName>

Obligor:

<Name>

<RPCity,State,Zip>

Obligee:

Case Number: Order Number

<Name>

Date: <Print Date>

Ohio Department of Job and Family Services

CHILD SUPPORT FINANCIAL AFFIDAVIT

The information requested below is needed for the CSEA to accurately calculate the amount of child support to be paid and to allocate the costs of providing for the health care needs of the children between the parents.

Please complete each applicable field clearly, providing the most information you can, including any partial information. Please supply copies of any information requested. If you need additional space to provide complete responses, please attach additional pages.

A. YOUR INFORMATION
Last Name		First Name		Middle Initial
Residential Address				Apartment/Unit #
City		State		Zip
Mailing Address				Apartment/Unit #
City		State		Zip
Date of Birth	SSN		Email
Home Phone	Cell Phone		Other Phone(s)

B. LIST THE MINOR CHILD(REN) OF THIS ORDER
Child 1	SSN	DOB	Does this child primarily reside with you? YES NO
Child 2	SSN	DOB	Does this child primarily reside with you? YES NO
Child 3	SSN	DOB	Does this child primarily reside with you? YES NO
Child 4	SSN	DOB	Does this child primarily reside with you? YES NO
C. DAY CARE COSTS FOR THE CHILDREN OF THIS ORDER
Do you pay day care for children of this order so that you can go to work or school? YES NO Child's name: Amount $_ /annually Child's name: Amount $_ /annually Child's name: Amount $_ /annually Child's name: Amount $_ /annually

If you answered yes, you must attach proof of payments in the form of receipts, canceled checks, or notarized statement from the child care provider.

JFS 00593 (2/2014) Page 1 of 4

If you filled out this section, you must attach proof (i.e. an award letter) of the frequency and amount of the monthly benefits.

E.	DO YOU HAVE OTHER NATURAL OR ADOPTED MINOR CHILDREN NOT LISTED ABOVE? YES NO
Name		DOB	Does this child live with you? YES NO
I receive	pay $ _/month		Case No. _ County/State
Name		DOB	Does this child live with you? YES NO
I receive	pay $ _/month		Case No. _ County/State
Name		DOB	Does this child live with you? YES NO
I receive	pay $ _/month		Case No. _ County/State
Name		DOB	Does this child live with you? YES NO
I receive	pay $ _/month		Case No. _ County/State

If you filled out this section, you must attach proof of birth certificate(s), adoption paper(s), copies of order(s), and/or proof of payment(s).

F. SPOUSAL SUPPORT

Do you receive Spousal Support? YES NO I receive $ /month County/State

Do you pay Spousal Support? YES NO I pay $ _/month County/State _

G. MILITARY Attach a copy of your Leave and Earnings Statement(LES)
Do you receive pay from the military? YES NO Basic $ _/mo. BAS $ _/mo. BAH $ _/mo.
Rank Branch _ Years of Service
Military Status:
	Active	Reserve	Retired	Other

H. EMPLOYMENT INFORMATION
Are you employed? YES If yes, when did you begin employment? _ NO If NO, skip to section I. Work History
Employer 1		Address (Payroll address, if different)			Phone
Full Time Part Time Seasonal		Paychecks received Weekly Bi-Weekly Monthly Other
Salary $ /per month Hourly $ /per hr			Hours Worked Per Week
Overtime $ _ Last Year $ 2 Years ago $ 3 Years ago
Bonuses $ Last Year $ 2 Years ago $ 3 Years ago
Commission $ _ Last Year $ 2 Years ago $ 3 Years ago

Do you have a second job? YES NO
Employer 2	Address					Phone
Full Time Part Time Seasonal	Paychecks received Weekly Bi-Weekly Monthly Bi-Monthly Other
Salary $ _/per month Hourly $ /per hr				Hours Worked Per Week
Overtime $ _ Last Year $ 2 Years ago $ 3 Years ago

Bonuses $ Last Year	$ 2 Years ago	$ 3 Years ago
Commission $ _ Last Year	$ 2 Years ago	$ 3 Years ago

ARE YOU SELF EMPLOYED? YES NO

Name of business:

Type of business: _

Self-employment total gross receipts: $

Ordinary and necessary business expenses: $

I. WORK HISTORY

LIST YOUR LAST 3 EMPLOYERS:

Employer Name & Address: Date of employment: to

Last Pay Rate $

Reason for leaving:

Employer Name & Address: Date of employment: to

Last Pay Rate $

Reason for leaving:

Employer Name & Address: Date of employment: to

Last Pay Rate $

Reason for leaving:

My usual occupation is

Last grade of school completed

Degree(s), Certificate(s), or Professional License(s):

Are you medically disabled? YES NO If yes, provide proof of disability.

J. DO YOU RECEIVE FUNDS FROM THE FOLLOWING SOURCES? Check all that apply and attach verification

I receive $ per _ from pensions or retirement accounts __(list source) I receive $ per _ from Supplemental Security Income (SSI)

I receive $ per _ from Social Security Disability Benefits (SSD)

I receive $ per _ from annuities and/or dividends and/or other investment income I receive $ per _ from rental property

I receive $ per _ from unemployment compensation I receive $ per _ from Worker's Compensation

I receive $ per _ from _(list sources) Do you have a pending claim from an above source? YES NO If yes, list source: _ If you are not employed and do not receive any of the above benefits, please explain how you support yourself.

K. CITY TAXES AND OTHER MANDATORY DEDUCTIONS Attach a copy of last year's completed tax form

Do you pay local (city) income tax? YES NO If yes, amount $ per

Do you pay required union dues/uniform /work expenses? YES NO If yes, amount $ per

L. HEALTH INSURANCE INFORMATION Attach copies of all health insurance cards

Do you currently have health insurance coverage? YES NO If yes, beginning date of coverage Is this health insurance available through: Employer Spouse's Employer State (i.e. Medicaid, etc) Other

Do the child(ren) have health care coverage? YES NO If no, is health insurance coverage available? YES NO

Is this health insurance available through: Employer Spouse's Employer State (i.e. Medicaid, etc) Other

If coverage is provided or is available through your current spouse, please provide the following information about your spouse:

Spouse's name: Spouse's SSN: Spouse's address, if different from yours: Spouse's DOB:

List individuals currently covered by available health insurance:

Name Relationship Name Relationship Name Relationship Name Relationship

Name Relationship _

Name of health insurance company or union (provide union local number): Address: Phone number: _ Policy holder name:

Policy number: _ Group number: _ Type of insurance (i.e. medical, dental, etc):

Name of additional health insurance company or union (provide union local number): Address: Phone number: _ Policy holder name:

Policy number: _ Group number: Type of insurance (i.e. medical, dental, etc)

Please attach an additional sheet to supply information about any additional health insurance plans that provide coverage for the child(ren). Please attach copies of all health insurance cards.

M. COST OF HEALTH CARE INSURANCE IF AVAILABLE, REGARDLESS OF WHETHER YOU CURRENTLY CARRY IT

Medical

Single coverage cost: $ /mo.

Single plus dependent cost: $ /mo.

Family cost: $ /mo.

Dental

Single coverage cost: $ /mo

Single plus dependent cost: $ /mo.

Family cost: $ /mo.

Vision

Single coverage cost: $ /mo

Single plus dependent cost: $ /mo.

Family cost: $ /mo.

I have attached the following documentation (check all that apply):

W-2's, IRS 1099, and all other IRS forms and schedules from last year. If self employed, I have attached the previous three year of returns, including all accompanying schedules.

Six months of pay stubs

Disability letter from Workers Compensation or Social Security or a letter from a certified health care provider with my diagnosis and a determination stating how long I will be unable to work

Proof of any other non-employment income Copies of health insurance cards

Proof of my out-of-pocket costs to provide health insurance for my child(ren)

Proof of my out-of-pocket costs to provide child day care for my child(ren) while I'm at work or school

Proof of the amount of social security received by my child due to my or the other parent's disability or retirement Proof of children born or adopted by me not of this order (birth certificate, adoption decree)

NOTICE: Failure to provide all information and documentation necessary to support my request could result in the agency making reasonable assumptions regarding your income or filing of a motion for contempt for failure to comply with an administrative order. In addition, your employer could be subpoenaed, requiring them to produce records regarding your income and health care information. If you have any questions, please do not hesitate to contact the <County Name> County CSEA.

I hereby swear or affirm that the information contained or attached is true, correct and complete to the best of my knowledge.

Signature Print Name Date

<County Name-if known> County CSEA	Telephone:	<CSEA Local phone #-if known>
<CSEA Address 1-if known>	Toll Free:	<CSEA 800 #-if known>
<CSEA Address 2-if known>	Fax:	<CSEA Fax #-if known>
<CSEA City, State, ZIP-if known>

<Requester's first and last name>

Case Number: <SETS number>

Date: <Date>

Child Support Obligor: <Obligor's name>

Order Number: <order number> Child Support Obligee: <Obligee's name>

Ohio Department of Job and Family Services

RESCHEDULING ADMINISTRATIVE ADJUSTMENT HEARING NOTICE

You are hereby notified that an Administrative Adjustment Hearing has been re-scheduled for

<Date>, <Time> <AM/PM> at <County> County CSEA to discuss the amount of child support to be ordered based on the Child Support Enforcement Agency's recommendations made from your review held on <Review Date>.

Each party shall be given the opportunity to present evidence and testimony to support his/her contention that the Child Support Enforcement Agency did not correctly evaluate the parents' income.

Parties may bring a legal or other authorized representative to the hearing.

A hearing decision shall be issued within ten days of the hearing and include findings of fact based upon the evidence presented at the hearing, relevant citations to the "Ohio Child Support Guidelines" and other applicable law, a conclusion regarding the amount of child support to be ordered effective the date of the recommendation.

<Hearing Officer>

<County> County CSEA

JFS 07633 (Rev. 2/2015)

<CSAEAC_NTAIMOEN> C:oTunotyBCSeEARefiled

Telephone:

DAT<ECS:E1A0_L/0OC9A/2L_0P1H4ON1E:_3N5O>PM

<CSEA_ADDR1> Toll Free: <CSEA_800_No>

<CSEA_ADDR2> Fax: <CSEA_Fax_No>

<CSEA_CITY>, <CSEA_ZIP> <CSEA_CITY>

<OBLIGOR_NAMEF> <OBLIGOR_NAMEL>

<OBLIGOR_ADDR1>

<OBLIGOR_ADDR2>

<OBLIGOR_CITY>, <OBLIGOR_ST> <OBLIGOR_ZIP>

Date: <PRINT_DATE>

Case Number: <CASE_NO> Child Support Obligor: <OBLIGOR_NAMEF>

<OBLIGOR_NAMEL>

Order Number: <Order_No> Child Support Obligee: <OBLIGEE_NAMEF>

<OBLIGEE_NAMEL>

Ohio Department of Job and Family Services

REQUEST FOR AN ADMINISTRATIVE REVIEW OF THE CHILD SUPPORT ORDER

I request an administrative review and adjustment of my child support order, including the medical support provisions and any arrears payments, as set forth in Ohio Administrative Code (OAC) rules 5101:12-60-05 to 5101:12-60-05.6 for the following reason (please check the appropriate box):

• Note: I understand that the income amounts and changes in circumstances that warrant a review apply to the parents of the child support order. Income and circumstances of a caretaker do not warrant a request for a review of the child support order and are not used in the calculation of the child support orders.

It has been at least 36 months since the date of the most recent child support order.

It has been less than 36 months ago since the date of the most recent child support order. I have marked the appropriate circumstance which has changed and submitted the required documentation with this request.

1. The existing order established a minimum or a reduced amount of support based on the Child Support Guidelines due to the unemployment or underemployment of one of the parents and that parent is no longer unemployed or underemployed. Documentation required and attached.

2. I am The other party is unemployed or laid off beyond the party's control for thirty consecutive days. This does not include seasonal employment. Documentation required and attached.

3. I am The other party is unemployed or laid off due to a plant closing or mass layoff as defined in the Worker Adjustment and Retraining Notification (WARN) Act, 29 U.S.C. §2101 et seq. The administrative review request may only be made after the worker's last day of employment. Documentation required and attached.

4. I am The other party is permanently disabled reducing his or her earning ability. The requestor must provide to the CSEA verification of receipt of benefits administered by the Social Security Administration due to the disability and/or a physician's complete diagnosis and permanent disability determination. Documentation required and attached.

5. I am The other party is institutionalized or incarcerated and cannot pay support for the duration of the child's minority and no income or assets are available to the party which could be levied or attached for support. The requestor must provide evidence of the institutionalization or incarceration and the inability to pay support during the child's minority. Documentation required and attached.

6. I have The other party has experienced a thirty percent increase or decrease in gross income for a period of six months which can reasonably be expected to continue for an extended period of time. Documentation required and attached.

7. The child support order is not in compliance with the Ohio Child Support Guidelines due to the termination of the support obligation for a child of the existing support order.

8. I have children by the same parent in two or more administrative child support orders and I want to combine the

JFS 01849 (Rev. 2/2015) Page 1 of 2

orders into a single administrative child support order.

9. I want to access available or improved private health insurance coverage that is available for the child.

Documentation required and attached.

10. I have The other party has experienced an increase or decrease in the cost of ordered private health insurance coverage or child care for the child which is expected to result in a change of more than ten percent to the child support obligation based on the current Child Support Guidelines calculation. Note, if the request is based on a change in the cost of private health insurance, the requesting party must provide to the CSEA evidence regarding the cost of a family plan and the cost of an individual plan. Documentation required and attached.

11. The private health insurance that is currently being provided in accordance with the child support order is no longer reasonable in cost and/or accessible. Documentation required and attached.

12. I am the obligor and I assert that my annual gross income is now below 150% of the federal poverty level and I should not be ordered to pay cash medical support (the federal poverty guidelines can be found at http://www.aspe.hhs.gov/poverty or by contacting the CSEA). Documentation required and attached.

13. I am the obligor and I am a member of the uniformed services who has been called to active service for a period of more than thirty (30) days. I have attached a military Power of Attorney to permit a designated person to act on my behalf in the administrative review, if applicable. Documentation required and attached.

14. A temporary adjustment order pursuant to OAC rule 5101:12-60-05.2 was issued, the obligor's term of active military service has ended, and the obligor has provided the CSEA written documentation sufficient to establish that the obligor's employer has violated the Uniformed Services Employment and Reemployment Rights Act, 38 U.S.C. 4301 to 4333. Documentation required and attached.

Ohio law requires that a local CSEA provide child support enforcement services on all child support cases, including the review and adjustment of a child support order. However, a "IV-D case" is eligible for additional services that are not available to a "non-IV-D case." If you have a "non-IV-D case," you may contact the CSEA for information about completing a IV-D application

Within 15 days of receiving your request for an administrative review and adjustment and any required evidence, the CSEA will review your request and determine whether a review should be conducted.

If your request is approved, both parties to the order and any third party caretakers will be notified of the date of the administrative review. The notice will be mailed to the last known address of all parties. The notification will also request that you provide financial information, including but not limited to completing a financial affidavit, medical support information, and any other information necessary to properly review the child support order.

If your request is denied, the CSEA will send you notice of denial.

Requesting an administrative review may result in the monthly support obligation increasing, decreasing, or remaining the same or in a change in the medical support provisions. Please be aware that you may not withdraw your request for an administrative review on or after the scheduled review date.

Please provide your current address if different from page 1. Address:

I have attached all required and relevant documentation in support of my request. I understand that if the required

documents are not attached, my request will be denied.

Signature Date

Printed Name

Phone Number Email

JFS 01849 (Rev. 2/2015) Page 2 of 2

<County Name> County CSEA

Telephone:

Toll Free: Fax:

		Date:	<print date>
Obligor:	<obligor's first and last names>	Case Number:	<Case #>
Obligee:	<obligee's first and last names>	Order Number:	<order #>

Ohio Department of Job and Family Services

CARETAKER NOTIFICATION OF ADMINISTRATIVE ADJUSTMENT REVIEW

In accordance with Ohio Revised Code (ORC) section 3119.60, the <County Name> County Child Support Enforcement Agency (CSEA) will conduct a review to determine if an adjustment (increase or decrease) to the current child or cash medical support obligation or any arrears payment is warranted. The CSEA may also review the support order with regard to medical support provisions to ensure the children under the order are covered by private health insurance and/or cash medical support.

This review is scheduled for <scheduled date>. This is a desk review and it is not necessary for you to be present. An administrative adjustment recommendation will be forwarded to you by mail with further instructions.

The mother and father are required to complete a financial affidavit and provide verifications to be used by the CSEA in completing a review of the child support orders. You do not need to provide any information for the review of the order. During the review, the CSEA will consider all information and verifications provided by both parents as well as any other relevant information and records available to the CSEA.

When the review is completed, a Recommendation regarding the child and cash medical support orders and health care provisions will be mailed to you, and will explain what steps you can take if you disagree with the Recommendations.

The CSEA and the agency attorney(s) represent the interests of the State of Ohio; not the parties to the support order. The CSEA does not have the authority to address tax exemption, custody, visitation, or to deviate from the Ohio Child Support Guidelines. Should you have any questions, please call us at <CSEA Local phone #> or at

<CSEA 800 #>. You can fax us at <CSEA Fax #>.

<Worker's Name>

<Title>

<County Name> County CSEA

JFS 00592 (2/2015)

<County Name> County CSEA	Telephone:	<CSEA Local phone#>
<CSEA Address 1>	Toll Free:	<CSEA 800 #-if known>
<CSEA Address 2>	Fax:	<CSEA Fax #-if known>
<CSEA City, State, ZIP>

<Requestor's first and last name>

<Requestor's Address 1>

<Requestor's Address 2>

Child Support Obligor: <NCP Name>

Date:

Case Number:

<Date>

Child Support Obligee: <CP Name> Order Number: <order number>

Ohio Department of Job and Family Services

ADMINISTRATIVE ADJUSTMENT HEARING DECISION

(ORC 3119.61 and 3119.63)

This matter came on for administrative hearing on <Hearing Date> upon the request of <Requesting Party> which was filed with this agency on <Date Hearing Requested>.

The findings and recommendations of the Hearing Officer are attached.

Right to Request a Hearing

Administrative Child Support Orders

If either party disagrees with the decision of the Hearing Officer that person may object to the revised order by initiating an action under section 2151.231 of the Ohio Revised Code in the juvenile court or other court with jurisdiction under section 2102.22 or 2301.03 of the Ohio Revised Code.

Court Child Support Orders

If either party disagrees with the decision of the Hearing Officer that person may request a court hearing on the revised amount of child support.

Upon being notified of a request for a court hearing on either an administrative or court child support order, the CSEA shall submit the "administrative adjustment hearing record" to the court. The CSEA's only requirement is to submit the record to the court. The CSEA does not represent either party at the court hearing.

The CSEA's legal representative shall serve primarily in an administrative function rather than as a legal advocate. If a legal challenge occurs at the court hearing and the CSEA is requested to appear, the CSEA shall present the facts of the original decision to the court and explain the CSEA's original decision.

If neither party files a request for a court hearing on the revised amount within 15 days of the date of this notice, the CSEA shall submit the revised amount, if any, to the court for inclusion in a revised child support order.

Administrative Hearing Officer

JFS 07770 (Rev. 2/2015)

<County Name> County CSEA Phone: <CSEALocalPhone>

<City, State, Zip>

<Obligor's/Obligee's first and last name>

<City, State, and Zip>

		Date:	<print date>
Case Number:	<case number>	Obligor:	<Obligor's Name>
Order Number:	<order number>	Obligee:	<Obligee's Name>

Ohio Department of Job and Family Services

DISMISSAL OF ADMINISTRATIVE REVIEW REQUEST

Please be advised that the party who requested the administrative review failed to submit the required documents requested by the Child Support Enforcement Agency (CSEA) for the completion of the administrative review. As a result, the CSEA has dismissed the requesting party's request for an administrative review.

Both parties have the right to submit a new, written request for an administrative review by completing the JFS 01849, "Request for Administrative Review of the Support Order," which is attached. Upon receipt of the JFS 01849, the CSEA will determine if the request meets the criteria outlined in the JFS 01849. The CSEA has the discretion to deny a request for an administrative review if it is determined that the requesting party has submitted frequent requests.

<Worker's Name>

<Title>

JFS 01868 (Rev. 2/2015)

ACTION: To Be Refiled DATE: 10/09/2014 1:35 PM

<County Name> County CSEA Phone: <CSEA Local phone #>

<obligor's first and last names>

<obligor's address 1>

<Obligor's City, State, ZIP>

Case Number: <SETS number> Child Support Obligor: <Obligor's name>

Order Number: <order number> Child Support Obligee: <Obligee's name>

Ohio Department of Job and Family Services

NOTICE OF RIGHT TO REQUEST ADMINISTRATIVE REVIEW OF CHILD AND MEDICAL SUPPORT ORDER

This notice is to advise you of your right to request an Administrative Review of your child support and medical support order and, if appropriate, adjust the child support order to be consistent with the Ohio Child Support Guidelines set forth in Chapter 3119 of the Ohio Revised Code and the medical support order to be consistent with section 3119.30 of the Ohio Revised Code.

You may request an administrative review 36 months after the most recent support order was established or modified. You may request an administrative review earlier than 36 months if you can provide proof that you meet one of the criteria listed below:

1. A parent of the order is unemployed or laid off for thirty consecutive days or longer through no fault of your own and the unemployment or layoff is expected to continue.

2. A parent has become unemployed due to a plant closing or mass layoff.

3. A parent is permanently disabled.

4. My child support order was for a reduced or minimum amount based on the obligor being unemployed or underemployed and the obligor is now employed or more gainfully employed.

5. A parent has experienced a thirty per cent decrease, which is beyond the party's control, or a thirty per cent increase in gross income or income-producing assets for a period of at least six months which can reasonably be expected to continue for an extended period of time.

6. A parent is incarcerated with no chance of parole or are institutionalized and cannot pay support during the child's minority.

7. The order is not in compliance with the child support guidelines due to the termination of support for a child of the existing order.

8. I have children by the same parent in two or more administrative child support orders and I want to combine the orders into a single administrative child support order.

9. A parent has experienced an increase or decrease in the cost of child care or ordered health insurance coverage and I believe the increase or decrease will result in a greater than 10% increase or decrease to the support order.

10. I want to access available or improved health insurance coverage for the child.

11. The private health insurance that is currently ordered is no longer available at a reasonable cost.

12. I am the obligor and my annual gross income is below 150% of the federal poverty level.

13. I am the obligor and a member of the uniformed services and have been called to active military service for a period of more than thirty days or a temporary support order adjustment has been issued and the term of active military service has ended.

14. A temporary adjustment order was issued due to the obligor's active military service and the term for active military service has now ended.

If you wish to request an administrative review, please contact the CSEA at the number listed above.

JFS 07049 (Rev. 2/2015)

<CSEA_NAME> County CSEA Telephone: <CSEA_LOCAL_PHONE_NO>

<CSEA_ADDR1> Toll Free: <CSEA_800_No>

<CSEA_ADDR2> Fax: <CSEA_Fax_No>

<CSEA_CITY>, <CSEA_ST> <CSEA_ZIP>

<Hearing_Requestor_Name>

<HEARING_REQUESTOR_ADDR1>

<HEARING_REQUESTOR_ADDR2>

<Hearing_Requestor_City>, <HEARING_REQUESTOR_ST> <Hearing_Requestor_ZIP>

Child Support Obligor: <OBLIGOR_NAMEF>

<OBLIGOR_NAMEL>

Date:

Case Number:

<PRINT_DATE>

<CASE_NO>

Child Support Obligee: <OBLIGEE_NAMEF>

<OBLIGEE_NAMEL>

Order Number: <Order_No>

Ohio Department of Job and Family Services

DENIAL OF REQUEST TO RESCHEDULE ADMINISTRATIVE REVIEW & ADJUSTMENT HEARING

The <CSEA_NAME> County Child Support Enforcement Agency has denied your request to reschedule the Administrative Adjustment Hearing which it received on <Hearing_Request_Date> for the following reason:

[<1>] The CSEA determined that circumstances did not exist which would reasonably prevent your participation.

[<2>] The request was not received prior to the hearing scheduled date.

<Primary_Worker_Name> CSEA Representative

JFS 01856 (Rev. 2/2015)

<County Name> County CSEA Phone: <CSEA Local phone #>

<CSEA Address 1> Toll Free: <CSEA 800 #>

<Requestor's Name>

<Requestor's Address 1>

<Requestor's Address 2>

<Requestor's City, State, Zip>

		Date:	<print date>
Case Number:	<case number>	Obligor:	<Name of NCP>
Order Number:	<order number>	Obligee:	<Name of CP>

Ohio Department of Job and Family Services

ADMINISTRATIVE REVIEW PENDING NOTICE

Please be advised that the Child Support Enforcement Agency (CSEA) cannot complete the Administrative Review and Adjustment until it has located the other party to the order, <Name of unlocatable party> . This is because the CSEA is required to notify the obligor and the obligee of the result of the administrative review and their rights to request an administrative or court hearing.

If you know the current address of the other party, please contact the CSEA at the address or phone number listed above as soon as possible.

When a valid address for the other party is obtained, the CSEA will complete the administrative review and adjustment process and you will receive a copy of the Administrative Review Recommendations.

Until the CSEA obtains a valid address for the other party, the administrative review cannot be finalized. However, the final recommended effective date of any adjustment to the support order will not be affected by this delay. The recommended effective date of any adjustment will be <date>.

<Worker's Name> CSEA Representative

JFS 01866 (Rev. 2/2015)

<County Name> County Name Phone: <CSEA Local phone #>

		Date:	<print date>
Case Number:	<case number>	Obligor:	<NCP Name>
Order Number:	<order number>	Obligee:	<CP Name>

Ohio Department of Job and Family Services

RIGHT TO REQUEST AN ADMINISTRATIVE REVIEW OF THE SUPPORT ORDER

Please be advised that it has been three years or more since your support order was issued or adjusted. You are entitled to have an administrative review of your child support and health insurance order to determine if it should be adjusted (increased or decreased) once every three years. In most cases, when the obligee is receiving public assistance (Ohio Works First), the CSEA would automatically initiate an administrative review when three years or more has elapsed since the support order was issued or adjusted. However, you have established good cause that does not require you to cooperate with the CSEA. Because of the good cause determination, the CSEA will not automatically initiate the administrative review of the child support order. You may, though, specifically request an Administrative Review.

If you want to waive the Good Cause determination in order to initiate an Administrative Review of the support order, you need to do the following:

* Sign the attached Waiver of Good Cause for Administrative Review and Adjustment Purposes Only,

* Sign the attached Request for Administrative Review and Adjustment, and

* Return both the Waiver and the Request to the CSEA.

If you do not want an Administrative Review of the support order, you do not need to do anything. Your Good Cause determination will remain in effect and the CSEA will not initiate an Administrative Review. Please note that, even if the CSEA does not initiate an Administrative Review at this time, the other party may request one now or in the future and the CSEA will be required to comply with the request.

<Worker's Name> CSEA Representative

JFS 01867 (Rev. 2/2015) Page 1 of 2

WAIVER OF GOOD CAUSE DETERMINATION FOR ADMINISTRATIVE REVIEW AND ADJUSTMENT PURPOSES ONLY

Case Number:	<case number>	Obligor:	<NCP Name>
Order Number:	<order number>	Obligee:	<CP Name>

I, the obligee in the above mentioned case, hereby request that my good cause determination be waived but only for the purpose of initiating and conducting an Administrative Review of my support order. I understand that my case will remain in a confidential caseload and information about me and the child(ren) will not be released to the other party. I also understand that the CSEA will not expect me to cooperate in enforcing the support order. This Waiver of Good Cause Determination will only apply to the attached Request for Administrative Review and will not be used for any future Administrative Reviews.

Signature of Obligee

Date

REQUEST FOR AN ADMINISTRATIVE REVIEW AND ADJUSTMENT OF THE SUPPORT ORDER

I request an administrative review and adjustment of my child support order as set forth in rule 5101:12-60-05.1 of the Ohio Administrative Code.

Within 15 days of receiving your request for an administrative review and adjustment, the CSEA will review your request and determine whether a review should be conducted. Both parties to the order will be notified of the review date, time, and location. The notice will be mailed to the last known address of both parties. The notification will also request that you provide financial information and any other information necessary to properly review the child support order.

Please be aware that you may not dismiss your request for an administrative review on or after the scheduled review date.

Signature of Obligee

Date

JFS 01867 (Rev. 2/2015) Page 2 of 2

<County Name> County CSEA Telephone: <CSEA Local phone #>

<1st copy to obligor's and 2nd copy to obligee's first and last names>

Date: <print date>

Case Number: <SETS number> Child Support Obligor: <Obligor's name>

Order Number: <order number> Child Support Obligee: <Obligee's name>

Ohio Department of Job and Family Services

ADMINISTRATIVE ADJUSTMENT REVIEW NOTIFICATION

In accordance with Ohio Revised Code (ORC) section 3119.60, the <County Name> County Child Support Enforcement Agency (CSEA) will conduct a review to determine if an adjustment (increase or decrease) to your current child or cash medical support obligation or your arrears payment is warranted. The CSEA may also review the support order with regards to medical support provisions to ensure the children under the order are covered by private health insurance and/or cash medical support.

Your review is scheduled for <scheduled date>. This is a desk review and it is not necessary for you to be present. An administrative adjustment recommendation will be forwarded to you by mail with further instructions.

However, you must complete and return the attached JFS 00593, "Child Support Financial Affidavit" and provide all mandatory verifications as soon as possible but no later than <scheduled date>. During the review, the CSEA will consider all information and verifications provided by both parties as well as any other relevant information and records available to the CSEA. If you fail to provide any required information or documents, it could result in unnecessary delays, your child and cash medical support obligations being calculated based on reasonable assumptions made regarding your income, a subpoena being issued to your employer to produce evidence regarding your income and health care benefits, your request for an administrative adjustment review being dismissed, or possible legal action to obtain the required information. Pursuant to ORC section 3119.72, failure to comply with this request for information may be enforced by requesting the court find you in contempt.

The CSEA and the agency attorney(s) represent the interests of the State of Ohio; not the obligor or obligee. The CSEA does not have the authority to address tax exemption, custody, visitation, or deviate from the Ohio Child Support Guidelines. Should you have any questions, please call us at <CSEA Local phone #> or at <CSEA 800 #>. You can fax us at <CSEA Fax #>.

WAIVER

I would like the administrative review to be conducted on which is sooner than the date indicated above. I am submitting this Waiver, the Affidavit, and all mandatory verifications within ten (10) days of the date indicated above. If I and the other party return the Waiver, the CSEA will conduct the administrative review on the date specified and agreed upon by both parties and the CSEA. If the parties fail to agree upon a date, the administrative review shall occur on <scheduled date>.

Signature:

Date:

Your Address:

JFS 07606 (Rev. 2/2015)

<County Name> County CSEA

Telephone: <CSEA Local phone> Toll Free: <CSEA 800 #>

Fax: <CSEA Fax #>

<Requestor's first and last name>

<Requestor's Address 1>

<Requestor's Address 2>

Child Support Obligor: <NCP Name>

Date: <Date>

Case Number: <case number>

Child Support Obligee: <CP Name> Order Number: <order number>

Ohio Department of Job and Family Services

DENIAL OF REQUEST FOR AN ADMINISTRATIVE ADJUSTMENT HEARING

The <County Name> County CSEA received your request for an Administrative Adjustment Hearing on

<Date Request Received>. Your request for a hearing is denied for the following reason:

The request was unrelated to Adjustment Recommendations

The request was made by an individual who is not a party to the support order and not an authorized representative.

Your order is a court support order and the request was not made within 14 calendar days plus 3 business days of the issuance of the JFS 07724 for a court hearing, or for an administrative hearing.

Your order is an administrative support order and the request was not made within 30 calendar days plus 3 business of the issuance of the JFS 07724 for an administrative hearing.

If your request for an Administrative Adjustment Hearing was submitted timely you have the right to have the court review the recommendations pursuant to section 3119.63 of the Ohio Revised Code. To request a court hearing, you must file your request with the court. If the CSEA does not receive notification of the request for a court review within fifteen (15) days for the issuance of the denial, the recommendation will be submitted to the court for inclusion in a revised support order.

If the support order is an administrative order, you may object to the recommendations by initiating an action under section 2151.231 of the Revised Code in the juvenile court or other court with jurisdiction under section 2101.022 or 2301.03 of the Revised Code of the county in which the mother, father, child, or the guardian or custodian of the child resides.

JFS 07728 (Rev. 2/2015)

<County Name> County CSEA	Telephone Number:	<CSEA Local#>
<CSEA Address 1>	Toll Free Number:	<CSEA 800 #>
<CSEA Address 2>	Fax Number:	<CSEA Fax #>
<CSEA City, State, ZIP>

<City, State, Zip>

Date:

Case Number: Order Number:

Child Support Obligor: Child Support Obligee:

<Obligor's name>

<Obligee's name>

Ohio Department of Job and Family Services

ADMINISTRATIVE ADJUSTMENT HEARING NOTICE

Text Box: Type of Hearing: Adjustment and Review Mistake of Fact Date of Hearing: <Date>
Time of Hearing: <Time>

Location: <CountyCSEA Name>
<CSEA Address 1>
<CSEA City, State, ZIP>

You are hereby notified that an administrative adjustment hearing has been scheduled to discuss the amount of child support you are entitled to receive or pay based on the Child Support Enforcement Agency's recommendations made from your review held on <Review Date>.

Each party shall be given the opportunity to present evidence and testimony to support his/her objection to the Recommendation.

Parties may bring a legal or authorized representative to the hearing.

If you cannot appear at the above scheduled date and time, please contact this office immediately. If you requested this hearing and fail to appear, your objection may be dismissed.

A hearing decision will be issued within ten (10) days of the hearing. The decision will include findings of fact based upon the evidence presented at the hearing and relevant Ohio law.

<County> County CSEA

JFS 07602 (Rev. 2/2015)

<County Name> County CSEA	Phone:	<CSEA Local phone #>
<CSEA Address 1>	Toll Free:	<CSEA 800 #>
<CSEA Address 2>	Fax:	<CSEA Fax #>
<CSEA City, State, ZIP>

<obligor or obligee's first and last names>

		Date:	<print date>
Case Number:	<SETS number>	Child Support Obligor:	<Obligor's name>
Order Number:	<order number>	Child Support Obligee:	<Obligee's name>

Ohio Department of Job and Family Services

ADMINISTRATIVE ADJUSTMENT REVIEW DENIAL NOTICE

This letter is being sent to you because your request for an administrative review of your child support order has been denied. Pursuant to rule 5101:12-60-05 and its supplemental rules, your request has been denied for the following reason:

YOU HAVE A RIGHT TO A STATE HEARING.

This notice is to tell you about action the local Child Support Enforcement Agency (CSEA) is taking on your case. If you do not understand this action, you should contact your caseworker. After discussing the reasons for the action with your caseworker, it is possible that the CSEA will change its decision or that you will agree with the action.

If you do not agree with this action, you have a right to a state hearing. A state hearing lets you or your representative (lawyer, friend, or relative) give your reasons against the action. The CSEA will also attend the hearing to present its reasons. A hearing officer from the Ohio Department of Job and Family Services willlisten to both sides but will not make a decision at the hearing. Instead, you will receive a written decision in the mail issued by the hearing authority.

If you want a hearing, we must receive your hearing request within 90 days of the mailing date of this notice. You do not need to return this form if you agree with the action.

If someone else makes a written request for a state hearing for you, it must include a written statement, signed by you, telling us that person is your representative. Only you can make a request by telephone.

JFS 07613 (Rev. 2/2015) Page 1 of 2

If you want information on free legal services but do not know the number of your local Legal Aid office, you can call the Ohio State Legal Services Association toll free at 1-800- 589-5888, for the local number.

If you want a state hearing, check the box below, sign and date this form, and send it to the Ohio Department of Job and Family Services, Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825.

I want a state hearing on this action.

Signature Date: Phone

If you want a county conference, we must receive your request within 90 days of the mailing date of this notice. You do not need to return this form if you agree with this action. The county conference is with CSEA staff only.

If someone else makes a written request for you, it must include a written statement, signed by you, telling us that person is your representative.

If you want information on free legal services but do not know the number of your local legal aid office, you can call the Ohio State Legal Services Association toll free at 1-800-589- 5888, for the local number.

If you want a county conference, check the box below, sign and date this form and send it to the CSEA listed on page 1 or to the Ohio Department of Job and Family Services, Office of Child Support, P.O. Box 183203, Columbus, Ohio43218-3203.

I want a county conference

Signature Date: Phone

<County Name> County CSEA

JFS 07613 (Rev. 2/2015) Page 2 of 2

A<CCoTunItOy NNam: eT>oCoBunety RCSeEfiAled DATET:e1lep0h/o0ne9: /<2C0SE1A4L1oc:a3l p5hoPneM#>

Ohio Department of Job and Family Services

ADMINISTRATIVE ORDER

FOR CHILD SUPPORT AND MEDICAL SUPPORT

Original Order Modified Order

Date of Issuance: <print date>

Child Support Obligee Order Number

And

Child Support Obligor Case Number

<obligor SSN unless FVI> Obligor's Social Security Number

<obligor DOB> Obligor's Date of Birth

The <County Name> County Child Support Enforcement Agency (CSEA) hereby FINDS that <obligor first and last name> is the parent of the child(ren) named below:

Name of Child(ren) Date(s) of Birth

<child's first and last names> <child's DOB>

<obligor first and last name> has a duty of support for said child(ren) based on either a final Acknowledgment of Paternity Affidavit filed with the Central Paternity Registry, a presumption of paternity pursuant to section 3111.03 of the Ohio Revised Code (ORC), or an administrative paternity determination by the <County Name> County CSEA.

It is hereby ORDERED that:

PROVISIONS FOR CHILD SUPPORT

(A) The effective date of this Administrative Order for Child Support and Medical Support is <effective date>.

(B) <obligor first and last name> shall be the Child Support Obligor.

(C)(1) Starting on the first day of the month in which private health insurance is being provided in accordance with this order for the child(ren) named above, the Child Support Obligor shall pay $<monthly child support obligation when health insurance is provided> per month for current child support plus 2% processing charge, for a total of

$<monthly child support obligation when health insurance is provided + 2%) per month (Guidelines Worksheet attached).

(C)(2) Starting on the first day of the month in which either private health insurance is no longer being provided in accordance with this order for the child(ren) named above OR a Health Insurance Obligor has not yet been identified as indicated below, the Child Support Obligor shall pay $<monthly child support obligation when

JFS 07719 (Rev. 2/2015) Page 1 of 5

health insurance is not provided> per month for current child support, and $<monthly cash medical support obligation> per month for cash medical support plus 2% processing charge, for a total of $<monthly child support obligation when health insurance is not provided + monthly cash medical support obligation + 2%> per month (Guidelines Worksheet attached).

(C)(3) The Child Support Obligor shall pay $<monthly payment on arrears, if this is a modification of a child support order> per month plus 2% processing charge as payment on arrears.

(D) The duty of support imposed pursuant to this order shall continue beyond the child's eighteenth birthday only if the child continuously attends a recognized and accredited high school on a full-time basis on and after the child's eighteenth birthday. The order shall not remain in effect after the child reaches age nineteen. The obligor shall continue to pay support under the order, including during seasonal vacation periods, until the order terminates.

(E) The Child Support Obligor shall continue to pay any other existing orders which are not expressly modified herein.

(F) Payments are to be paid to Ohio Child Support Payment Central, P.O. Box 182372, Columbus, OH 43218. The Child Support Obligor shall make payments by certified check, money order, personal check, or traveler's check until such time as the payments are withheld by an income withholding or deduction notice. Include the case number and order number on all payments.

(G) Pursuant to ORC section 3121.27, all support under this order shall be withheld or deducted from the income or assets of the Child Support Obligor pursuant to a withholding or deduction notice or appropriate order issued in accordance with ORC Chapters 3119., 3121., 3123., and 3125. or a withdrawal directive issued pursuant to ORC sections 3123.24 to 3123.38 and shall be forwarded to the Child Support Obligee in accordance with ORC Chapters 3119., 3121., 3123., and 3125..

(H) The specific withholding or deduction requirements to be used to collect the support shall be set forth and determined by reference to the notices that are sent out by the CSEA in accordance with ORC section 3121.03 and shall be determined without the need for any amendment to the administrative support order. Those notices, plus the notices provided by the CSEA that require the Child Support Obligor to notify the CSEA of any change in his/her employment status or of any other change in the status of his/her assets, are final and are enforceable by the court. Each withholding notice shall be for the current child support, current cash medical support, any arrearage payment required under the administrative order, and processing charges.

(I) Pursuant to ORC section 3121.28, the Child Support Obligor and Child Support Obligee are hereby notified that, regardless of the frequency or amount of support payments to be made under the order, the CSEA shall administer the support order on a monthly basis, in accordance with ORC sections 3121.51 to 3121.54. For the purpose of monthly administration of support payments that are to be made other than on a monthly basis, the CSEA will calculate the monthly amount due in the following manner:

(1) If the support is to be paid weekly, the CSEA will multiply the weekly amount of support due under the support order by fifty-two and divide the resulting amount by twelve.

(2) If the support is to be paid biweekly, the CSEA will multiply the biweekly amount of support due under the support order by twenty-six and divide the resulting amount by twelve.

(3) If the support is to be paid periodically but not weekly, biweekly, or monthly, the CSEA will multiply the periodic amount of support due by an appropriate number to obtain the annual amount of support due under the support order and divide the annual amount of support by twelve.

If payments are to be made other than on a monthly basis, the required monthly administration of the support order shall not affect the frequency or the amount of the support payments to be made under the support order.

(J) Pursuant to ORC section 3121.45, any payment of money by the Child Support Obligor to the Child Support Obligee that is not made through Ohio Child Support Payment Central or the CSEA administering the support order shall not be considered a payment of support under the support order and, unless the payment is made to discharge an obligation other than support, shall be deemed to be a gift.

PROVISIONS FOR MEDICAL SUPPORT

In accordance with ORC section 3119.30 or 3119.32, the Child Support Obligor shall pay <percentage>% and the Child Support Obligee shall pay <percentage>% of the costs of the health care needs of the child(ren) named above that exceeds the amount of cash medical support ordered to be paid, if any, when private health insurance coverage is not available as indicated below, OR of the uninsured health care costs or co-payment or deductible costs required under the health insurance policy, contract, or plan that covers the child(ren) named above, when private health insurance coverage is available as indicated below.

If this box is checked, the CSEA has determined that private health insurance coverage is accessible and reasonable in cost through a group policy, contract, or plan available to <obligor's name, if sole person to provide health insurance>

<obligor and obligee names if both ordered to provide health insurance> <obligee's name, if sole person to provide health insurance>.

Therefore, in accordance with ORC section 3119.30, it is hereby ORDERED that, no later than thirty days after the issuance of this support order, <obligor's name, if sole person to provide health insurance> <obligor and obligee names if both ordered to provide health insurance> <obligee's name, if sole person to provide health insurance> shall secure and maintain private health insurance for the child(ren) named above and shall hereafter be referred to as the Health Insurance Obligor.

In accordance with paragraph (C) of ORC section 3119.30, it is further ORDERED that the Child Support Obligor shall pay cash medical support during any period in which the child(ren) named above are not covered by private health insurance pursuant to the support order.

In accordance with paragraph (I) of ORC section 3119.32, upon receipt by the CSEA of notice that private health insurance coverage is not available at a reasonable cost to the Health Insurance Obligor, cash medical support shall be paid in the amount as determined by the child support computation worksheet pursuant to ORC section 3119.022 or

3119.023. The CSEA may change the financial obligation of the parties to pay child support and cash medical support without a hearing or additional notice to the parties.

If this box is checked, the costs of private health insurance exceed the health insurance maximum indicated on line 7b of the Child Support Guidelines Computation Worksheet and: (a) both parents have agreed that one, or both, of the parents obtain or maintain the private health insurance that exceeds five per cent of the annual gross income of the parent obtaining or maintaining the private health insurance; or (b) either parent has requested to obtain or maintain the private health insurance that exceeds five per cent of that parent's annual gross income.

If this box is checked, the private health insurance is considered accessible when primary care services are not located within thirty miles of the child(ren)'s residence but are located farther than thirty miles from the child(ren)'s residence because residents in part or all of the child(ren)'s immediate geographic area customarily travel farther distances than thirty miles for primary care services.

If this box is checked, the custodial parent is dependent upon public transportation; therefore, private health insurance must also provide primary care services that are available by public transportation in order to be considered accessible.

If this box is checked, the CSEA has determined that private health insurance coverage is not accessible or reasonable in cost through any group policy, contract, or plan available to the Child Support Obligor or Child Support Obligee.

Therefore, in accordance with ORC section 3119.30, it is hereby ORDERED that if, after the issuance of this order, private health insurance coverage for the child(ren) named above becomes available through any group policy, contract, or plan available to the Child Support Obligor or Child Support Obligee, the Child Support Obligor or Child Support Obligee to whom the coverage becomes available SHALL IMMEDIATELY INFORM THE CSEA OF THE AVAILABLE COVERAGE. When the CSEA becomes aware through reporting by either party or by any other means that private health insurance may be available, the CSEA will then determine whether the private health insurance coverage is reasonable in cost. When the CSEA determines that the private health insurance coverage is reasonable in cost, the CSEA shall notify both parties that the person to whom the coverage is available is now the Health Insurance Obligor and is ordered to secure and maintain private health insurance for the child(ren) named above and to meet the requirements identified under "Notice to the Health Insurance Obligor" without an additional order or hearing.

In accordance with paragraph (C) of ORC section 3119.30, it is further ORDERED that the Child Support Obligor shall pay cash medical support during the period in which the child(ren) named above are not covered by private health

insurance and a health insurance obligor has not been identified. If a health insurance obligor is identified, the Child Support Obligor shall pay cash medical support during any period in which the child(ren) above are not covered by private health insurance pursuant to the support order. The cash medical support shall be paid in the amount as determined by the child support computation worksheet pursuant to ORC section 3119.022 or 3119.023.

NOTICE TO THE HEALTH INSURANCE OBLIGOR

1. Within thirty days of the date of this support order, the Health Insurance Obligor must designate the child(ren) named above as covered dependents under any health insurance policy, contract, or plan for which the Health Insurance Obligor contracts.

2. The individuals who are designated to be reimbursed by the health plan administrator for covered out-of-pocket medical, optical, hospital, dental, or prescription expenses paid for the child(ren) named above are:

Name: <obligor first and last name> Address: <obligor address, unless FVI> Phone: <obligor phone #, unless FVI>

Name: <obligee first and last name> Address: <obligee address, unless FVI> Phone: <obligee phone #, unless FVI>

3. The health plan administrator that provides the health insurance coverage for the child(ren) named above may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract, or plan.

4. The Health Insurance Obligor may be required to pay the co-payment or deductible costs required under the health insurance policy, contract, or plan that covers the child(ren) named above.

5. The Health Insurance Obligor's employer is required to release to the other parent, any person subject to an order issued under ORC section 3109.19, or the CSEA on written request any necessary information on the private health insurance coverage, including the name and address of the health plan administrator and any policy, contract, or plan number, and to otherwise comply with ORC section 3119.32 and any order or notice issued under ORC section 3119.32.

6. If the Health Insurance Obligor obtains new employment, the CSEA shall comply with the requirements of ORC section 3119.34, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child(ren) named above in private health care insurance coverage provided by the new employer.

7. Within thirty days of the date of this support order, the Health Insurance Obligor must provide to the other party information regarding the benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under the coverage, and a copy of any necessary insurance cards.

NOTICE TO REPORT REASON WHY SUPPORT ORDER SHOULD TERMINATE

PURSUANT TO ORC SECTIONS 3119.87 AND 3119.88

The Child Support Obligee shall immediately notify and the Child Support Obligor may notify the CSEA of any reason for which the child support order should terminate. Reasons for which a child support order should terminate include all of the following:

A. The child's attainment of the age of majority if the child no longer attends an accredited high school on a full-time basis;

B. The child ceasing to attend an accredited high school on a full-time basis after attaining the age of majority;

C. The child's death;

D. The child's marriage;

E. The child's emancipation;

F. The child's enlistment in the armed services;

G. The child's deportation; or

H. Change of legal custody of the child.

NOTICE TO CHILD SUPPORT OBLIGOR AND OBLIGEE PURSUANT TO ORC SECTION 3121.29

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

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

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

Both the Child Support Obligor and Child Support Obligee have a right to request an administrative review of the support order for child support and medical support thirty-six months from the establishment of the order or from the date of the most recent support order or sooner, if certain circumstances are present. Contact the <County Name> County CSEA for further details.

NOTICE TO THE PARTIES OF AN

INITIAL ADMINISTRATIVE ORDER FOR CHILD SUPPORT AND MEDICAL SUPPORT

(This section applies only when box is checked)

In accordance with ORC section 3111.84, the mother or father of the child(ren) named above may object to this administrative support order by bringing an action for the payment of support and provision for health care under ORC section 2151.231 in the juvenile court or other court with jurisdiction under ORC section 2101.022 or 2301.03 of the county in which the CSEA that employs the administrative officer is located. The action shall be brought not later than thirty days after the date of the issuance of the administrative support order. If neither the mother nor the father brings an action for the payment of support and provision for health care within that thirty-day period, the administrative support order is final and enforceable by a court and may be modified only as provided in ORC Chapters 3119., 3121., and 3123..

NOTICE TO THE PARTIES OF THEIR RIGHT TO OBJECT

TO A MODIFIED ADMINISTRATIVE ORDER FOR CHILD SUPPORT AND MEDICAL SUPPORT WHEN AN ADMINISTRATIVE ADJUSTMENT HEARING HAS BEEN REQUESTED

(This section applies only when box is checked)

In accordance with ORC section 3119.61, the Child Support Obligor and Child Support Obligee may object to the modified support order by initiating an action under ORC section 2151.231 in the juvenile court or other court with jurisdiction under ORC section 2101.022 or 2301.03 of the county in which the mother, father, child, or guardian or custodian of the child resides.

Administrative Officer Date

<County Name> County CSEA

Please remit all child support payments to: Ohio Child Support Payment Central

P.O. Box 182372 Columbus, OH 43218

Visit the Official Version

Document Information

File Date:: 2014-10-09
CSI:: Yes
Rule File:: 5101$12-60-99_PH_TBR_A_RU_20141009_1335.pdf
RSFA File:: 5101$12-60-99_PH_TBR_A_RS_20141009_1335.pdf
Related Chapter/Rule NO.: (1): Ill. Adm. Code 5101:12-60-99. [Effective until 11/1/2015] Chapter 60 forms - order administration