custody agreed complaint to allocate parental rights ...

CUSTODY 

AGREED COMPLAINT TO ALLOCATE PARENTAL RIGHTS & RESPONSIBILITIES 

AND ESTABLISH A SHARED PARENTING PLAN 

BY A PARENT 

INSTRUCTIONS 

Attached are forms requesting that the Court allocate parental rights and responsibilities and 

establish shared parenting. ONLY USE IF YOU ARE THE PARENT OF THE CHILD(REN), 

NO OTHER CUSTODY ORDER EXISTS, AND BOTH PARENTS AGREE. 

These instructions are intended to be a general guide to help you get the forms filled out, 

filed with the Court, and properly before the Judge. These instructions are not intended to be a legal 

analysis of your request or advice as to whether you should win your request. They are merely to 

assist you in preparing and presenting your request. 

A. FILLING OUT THE FORMS - TYPEWRITTEN OR IN INK 

1. All of the enclosed forms should be filled out before you go to the Court to file them. The 

Clerk of Court’s staff will not help you in completing the forms. 

2. Complaint to Allocate Parental Rights and Responsibilities and Establish a Shared 

Parenting Plan - Fill in the name of the county and court division (i.e., Juvenile, Domestic 

Relations). You are the Plaintiff; the other parent is the Defendant. Fill in the address, 

telephone number, and birth date for both parties. Leave the lines after Case Number, Judge, 

and Magistrate blank. 

In paragraph 1, fill in your name as Plaintiff and the other parent’s name as Defendant. Fill 

in the child(ren)’s names and date(s) of birth. 

In paragraph 2, fill in either that you are married or IF UNMARRIED, the name of the father 

who acknowledged paternity or the case number if paternity was done in court. If paternity 

was done administratively through the Child Support Enforcement Agency, leave those two 

lines blank and fill in the administrative case number on the third line. 

In paragraph 3, list your reason(s) for wanting shared parenting. Start by stating who has 

custody (or is the residential parent and legal custodian) now and why the change is to take 

place. You do not have to list here all of the facts that support your request or everything 

that has happened to you that causes you to want to change the residential parent and legal 

custodian. However, you have to be specific enough so that the Judge will know from 

reading your Complaint the main reasons why you want to change the residential parent and 

legal custodian to shared parenting. 

Both parties sign. 

Agreed Complaint to Allocate Parental Rights and Responsibilities & Establish SPP (Library) Tab # 11 Page 1 of 32

Under Waiver of Service, both parties sign. 

3. Shared Parenting Plan - Complete the Shared Parenting Plan. Fill in the name of the 

county, court division (i.e., Juvenile, Domestic Relations), the Plaintiff/Petitioner and the 

Defendant/Petitioner. Leave Case No. blank. List child(ren’s) name(s) and birth date(s). 

Check the option which applies under each category; add details where applicable. Fill in 

all blanks that require the county name. Both parties sign and date Shared Parenting Plan. 

4. Entries (2) - Fill in the name of the count, court division, the Plaintiff and Defendant. 

5. Information For Child Custody Proceeding - This is a required form. Fill in the name of 

the county, court division, Plaintiff and Defendant. Fill in the requested information for each 

child. Answer questions 2 through 7. Do not sign the Affidavit until you are in front of 

a notary. 

6. Application for Child Support Services - This is a required form. Fill your name and the 

county you are requesting services from. Fill in the information requested in the applicant 

information block. On the second page, fill in the requested information. NOTE: You do 

not need to fill out this form if you are on OWF. 

7. Financial Disclosure/Affidavit of Indigency - This is a required form if you want the Court 

to waive pre-payment of court costs. Detailed instructions attached. 

8. Remove the instructions sheets and make three copies of each page of each form. 

B. FILING THE COMPLAINT 

1. After the forms are filled out and copied, YOU MUST TAKE THEM to the Clerk of Court’s 

office to be filed. 

2. When you file your Complaint, the Clerk's office staff will take the original and three copies 

of your papers. You should ask the Clerk to time-stamp your copy of the Complaint and 

accompanying forms. This will be your proof that you filed the originals. The Judgment 

Entries will not be file-stamped at this time. 

C. PREPARATION FOR THE HEARING 

1. Since both of you are in agreement about the change of residential parent and legal 

custodian, it is possible that the Court will sign the Judgment Entry changing custody and 

establishing a shared parenting plan without requiring a hearing. If a hearing is scheduled, 

you should follow the instructions below. 

2. You should present a neat appearance to the Court. The Court will not permit anyone to 

appear in court if s/he is wearing any of the following items of clothing: a hat, shorts, 

sandals, sleeveless shirts, tops, or blouses, clothing displaying indecent language or pictures, 


or clothing with large rips or holes. Your child(ren) may also be able to testify about the 

change of custody. 

3. The Judge will want to know basically these things: Why you want to change the residential 

parent and legal custodian (change of custody), what circumstances have changed that makes 

you and the other parent want to change custody, and whether the change is in the best 

interests of the child(ren). 

4. At the hearing you will be asked questions by the Judge or by an attorney. Respond directly 

to the question and make sure that you provide the information that you are asked for. If you 

do not understand the question or are not sure what you are being asked, you have the right 

to have the question explained to you before answering it. Never answer a question you do 

not understand. 

A WORD ABOUT MEDIATION 

The Court may order you and the other party to go to mediation. YOU MUST GO IF 

ORDERED. If there is a reason mediation would not be appropriate, you should tell the Court 

immediately. Mediation is a chance to work out issues without lengthy hearings. 


(Name) 

(Address) 

(City, State, Zip) 

(Telephone Number) 

(Birth Date) 

IN THE COURT OF COMMON PLEAS 

_________________ COUNTY, OHIO 

______________________ DIVISION 

* 

* 

* 

* 

* 

* 

Plaintiff/Petitioner, * CASE NUMBER _________________ 

vs. * JUDGE _________________________ 

(Name) 

(Address) 

(City, State, Zip) 

(Telephone Number) 

(Birth Date) 

Defendant/Petitioner. * 

* 

* 

* MAGISTRATE __________________ 

* 

* 

* 

* 

* 

AGREED COMPLAINT TO ALLOCATE PARENTAL RIGHTS AND 

RESPONSIBILITIES AND ESTABLISH A SHARED PARENTING PLAN 


1. ______________________________(Plaintiff) and ______________________________ 

(Defendant) are the parents of the children listed below: 

___________________________(Name of Child) 

___________________________(Name of Child) 

___________________________(Name of Child) 

___________________________(Name of Child) 

___/___/_____ (Child’s date of birth) 




2. The parties state that the parties are married or that the parties are unmarried and 

_________________________ acknowledged parentage of child(ren) pursuant to RC 

2105.18 {or parentage was determined pursuant to RC Chapter 3111 in case number 

____________ of the __________________________________ Court or through the child 

support enforcement agency in case number _______________. [Mark appropriate box] 

3. The parties state that it is in the best interests of the child(ren) to allocate parental rights and 

responsibilities and establish a shared parenting plan for the reasons set forth below: 

________________________________________________________________________ 

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WHEREFORE, the parties pray that the Court allocate both parties parental rights and 

responsibilities and shared parenting in accordance with the following Shared Parenting Plan. 

Agreed to by: 

Agreed to by: 

____________________________________ 

Plaintiff/Petitioner 

____________________________________ 

Defendant/Petitioner 

WAIVER OF SERVICE 

The parties, each being over 18 years of age and not under any disability, and each entitled 

to receive summons as a party in the above action, do each hereby waive service of summons in 

accordance with Rule 4(D) of the Ohio Rules of Civil Procedure and state that each have received 

a copy of this Agreed Complaint to Allocate Parental Rights and Responsibilities and Establish 

Shared Parenting voluntarily enter their appearances. 

___________________________________ 

Plaintiff/Petitioner 

___________________________________ 

Defendant/Petitioner 


IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, OHIO 

_______________________ DIVISION 

_____________________________________ 

Case No.: _______________ 

- vs / and - 

_____________________________________ 

Shared Parenting Plan 

The parties are the parents of the following children: 

Child’s Name 

Date of Birth 

The parties agree that they shall share parental rights and responsibilities for their minor 

child(ren) according to this shared parenting plan. 

A. Designation of Residential Parent and Legal Custodian: 

Each parent shall be the residential parent and legal custodian of the minor child(ren). 

If the parents are not residing in the same school district, (check the G that applies) G Mother G 

Father shall be the residential parent of the child(ren) for school district assignment 

purposes. 

B. Physical Living Arrangements: (Select one of the following options by checking the appropriate G) 

G (Option 1.) The child(ren) shall reside primarily with (check the G that applies) G Mother G 

Father and the other parent shall exercise parenting time as provided to “nonresidential” 

parents by the Court’s Standard Parenting Time Order. 


G (Option 2.) Each parent shall have liberal time with the child(ren) with the aim of 

maintaining a close relationship with both parents. In general, the child(ren) shall reside 

with Mother: (State the days and times the child(ren) will be with Mother. Attach separate sheet if 

necessary.) 

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and the child(ren) shall reside with Father: (State the days and times the child(ren) will be with 

Father. Attach separate sheet if necessary.) 

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C. Decision-Making: (Select one of the following options by checking the appropriate G) 

G (Option 1.) Mother and Father will cooperate in and discuss all matters affecting the 

child(ren) including, but not limited to, childcare; education; discipline; activities and 

hobbies (sports, music, dance, hunting, scouting, 4-H, etc…); religion and spirituality; 

grooming and hygiene; and health care (medical, dental, optical, psychological, etc…). 

Decisions shall be made jointly. If Mother and Father are unable to agree, they shall attempt 

to resolve the disagreement through mediation. 

G (Option 2.) Other (State how Mother and Father will make decisions about matters affecting the child(ren). 

Attach a separate sheet if necessary.) 


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D. Financial Support: 

______________________________ (Mother or Father) shall be the CHILD SUPPORT 

OBLIGOR. ______________________________ (Mother or Father) shall be the 

CHILD SUPPORT OBLIGEE. The child(ren) for whom the support is ordered is 

(are): 

Name: ______________________ 

Name: ______________________ 

Name: ______________________ 

Name: ______________________ 

DOB: _______________ 

DOB: _______________ 

DOB: _______________ 

DOB: _______________ 

(Select one of the following options by checking the appropriate G.) 

G (Option 1.) An administrative support order for the child(ren) is already in effect. The 

administrative child support order is incorporated into this Shared Parenting Plan and shall 

become part of the Court’s order for the allocation of parental rights and responsibilities for 

the child(ren). (Attach a copy of the administrative child support order to this Shared 

Parenting Plan.) The administrative child support order shall be terminated effective the 

last day of the month in which this plan is adopted by the Court and the court child support 

order shall become effective the first day of the following month. Any arrearages accrued 

under the administrative child support order shall be preserved and shall be transferred to 

this case. 

G (Option 2.) When private health insurance is being provided in accordance with this order 


for the child(ren) named above, the CHILD SUPPORT OBLIGOR shall pay $__________ 

per month for current child support plus 2% processing charge, for a total of $__________ 

per month. When private health insurance is not being provided in accordance with this 

order for the child(ren) named above, the CHILD SUPPORT OBLIGOR shall pay 

$__________ per month for current child support and $__________ per month for cash 

medical support plus 2% processing charge, for a total of $__________ per month. (The 

Guidelines Worksheet is attached.) The current child support obligation and cash medical 

support obligation shall continue as to each child until the child reaches the age of eighteen 

(18) years, the support obligor dies, the child dies, or the child becomes otherwise 

emancipated, whichever first occurs; however, as long as the child continuously attends on 

a full-time basis any recognized and accredited high school, the current child support 

obligation and cash medical support obligation shall continue until the child reaches the age 

of nineteen (19) years. The current child support obligation and cash medical support 

obligation shall continue during the child’s seasonal vacation periods. Any existing 

administrative child support order for the same child(ren) shall be terminated upon the 

effective date of the court child support order, subject to any arrearages or overpayments 

accrued through that date. 

G (Option 3.) When private health insurance is being provided, the CHILD SUPPORT 

OBLIGOR’s presumed child support obligation is $__________ per month. When private 

health insurance is not being provided, the CHILD SUPPORT OBLIGOR’s presumed child 

support obligation is $__________ per month for current child support and $__________ 

per month for cash medical support plus 2% processing charge, for a total of $__________ 

per month. (The Guidelines Worksheet is attached.) The parents agree that the presumed 

child support obligations are unjust or inappropriate to the child(ren) or either parent and that 

the presumed obligations are not be in the best interest of the child(ren) because of the 

following circumstances: 

_______________________________________________________________________ 

_______________________________________________________________________. 

Therefore, When private health insurance is being provided in accordance with this order for 

the child(ren) named above, the CHILD SUPPORT OBLIGOR shall pay $__________ per 

month for current child support plus 2% processing charge, for a total of $__________ per 

month. When private health insurance is not being provided in accordance with this order 

for the child(ren) named above, the CHILD SUPPORT OBLIGOR shall pay $__________ 

per month for current child support and $__________ per month for cash medical support 

plus 2% processing charge, for a total of $__________ per month. (The Guidelines 

Worksheet is attached.) The current child support obligation and cash medical support 

obligation shall continue as to each child until the child reaches the age of eighteen (18) 

years, the support obligor dies, the child dies, or the child becomes otherwise emancipated, 

whichever first occurs; however, as long as the child continuously attends on a full-time 

basis any recognized and accredited high school, the current child support obligation and 

cash medical support obligation shall continue until the child reaches the age of nineteen 

(19) years. The current child support obligation and cash medical support obligation shall 

continue during the child’s seasonal vacation periods. Any existing administrative child 

support order for the same child(ren) shall be terminated upon the effective date of the court 

child support order, subject to any arrearages or overpayments accrued through that date. 

The following applies in ALL CASES: 


All payments of support shall be made through the _____________ County Job and 

Family Services, Child Support Division, 1830 East Pike, P.O. Box 9, Zanesville, OH 

43702-0009 (open weekdays from 7:15 a.m. - 4:45 p.m.) or through Ohio Child Support 

Payment Central, P.O. Box 182372, Columbus, OH 43218. Payments by certified check, 

money order, personal check, or traveler's check MUST be made through Ohio Child 

Support Payment Central. The _____________ County Job and Family Services, Child 

Support Division, accepts ONLY cash payments, MasterCard, and VISA. Include the case 

number, the SETS number (an account number assigned by the Child Support Division), the 

name of Child Support Obligor, and the name of the Child Support Obligee with all 

payments. Any payment of money by the CHILD SUPPORT OBLIGOR to the CHILD 

SUPPORT OBLIGEE that is not made through the Ohio Child Support Payment Central, or 

the _____________ County Job and Family Services, Child Support Division, 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. 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. The 

_____________ County Job and Family Services, Child Support Division, shall issue the 

appropriate withholding or deduction notice. Both parents are notified that, regardless of the 

frequency or amount of support payments to be made under the order, the _____________ 

County Job and Family Services, Child Support Division, 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 _____________ County Job and Family Services, Child Support Division, will 

calculate the monthly amount due in the following manner: (1) If the support is to be paid 

weekly, 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, 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, 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. 

NOTICE TO CHILD SUPPORT OBLIGOR AND CHILD SUPPORT OBLIGEE 

EACH PARTY TO THIS SUPPORT ORDER MUST NOTIFY THE 

_____________ County Job and Family Services, Child Support Division, 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. 

The CHILD SUPPORT OBLIGEE shall notify, and the CHILD SUPPORT 

OBLIGOR may notify, the _____________ County Job and Family Services, Child Support 

Division, in writing, of any reason for which the support order should terminate including, 

but not limited to: 1) the child's attainment of the age of majority if the child no longer 


attends an accredited high school on a full-time basis and the support order does not provide 

for the duty of support to continue past the age of majority; 2) the child ceasing to attend 

such high school on a full-time basis after attaining the age of majority, if the support order 

does not provide for the duty of support to continue past the age of majority; or 3) the death, 

marriage, emancipation, enlistment in the armed services, deportation, or change in legal 

custody of the child. 

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. 

E. Health Insurance and Medical Support: 

Findings as to accessibility: (Select one of the following options by checking the appropriate G.) 

G Neither parent has private health insurance coverage that is accessible. 

G Both parents have private health insurance coverage that is accessible. 

G ______________________________ (Mother or Father) has private health insurance 

coverage available that is accessible. 

G Neither parent has private health insurance that provides primary care services within 

thirty miles of the child(ren)'s residence; however, this insurance is accessible 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. 

Findings as to reasonable cost: (Select one of the following options by checking the appropriateG.) 

G Neither parent has private health insurance coverage that is reasonable in cost. 

G Both parents have private health insurance coverage that is reasonable in cost. 

G ______________________________ (Mother or Father) has private health insurance 

coverage available that is reasonable in cost. The other parent does not have accessible 


coverage available at a more reasonable cost, does not have accessible coverage, or does not 

have coverage that is reasonable in cost. 

G Both parents have private health insurance coverage that is reasonable in cost. Dual 

coverage would provide for coordination of benefits without unnecessary duplication of 

coverage. 

G Neither parent has private health insurance available that is reasonable in cost; however, 

______________________________ (Mother or Father) requests to obtain or maintain the 

private health insurance even though it is not reasonable in cost. 

G Neither parent has private health insurance available that is reasonable in cost; however, 

they agree that ______________________________ (Mother or Father) shall obtain or 

maintain private health insurance even though it is not reasonable in cost. 

THEREFORE: (Select one of the following options by checking the appropriate G.) 

G (Option 1.) Because private health insurance that is accessible is not available to either 

parent at a reasonable cost, neither parent is ordered to secure and maintain private health 

insurance for the children at this time. If private health insurance coverage for the 

child(ren) named above becomes available through any group policy, contract, or plan 

available to either parent, the parent to whom the coverage becomes available shall 

immediately notify the _____________ County Job and Family Services, Child Support 

Division, of the available coverage. If the _____________ County Job and Family 

Services, Child Support Division, becomes aware that private health insurance may be 

available, it shall determine if the insurance is accessible and reasonable in cost. If the 

_____________ County Job and Family Services, Child Support Division, determines 

that the private health insurance coverage is accessible and reasonable in cost, it shall 

notify both parents that the person to whom the coverage is available is designated as 

the Health Insurance Obligor, that this parent is ordered to secure and maintain 

private health insurance for the child(ren), and that this parent shall comply with the 

requirements of the "Notice to the Health Insurance Obligor" set forth below without 

an additional order or hearing. 

G (Option 2.) ______________________________ (Mother or Father) shall secure and 

maintain private health insurance for the child(ren) named above no later than thirty days 

after the issuance of this support order. He or she is designated as the Health Insurance 

Obligor. 

G (Option 3.) Both Mother and Father shall each secure and maintain private health insurance 

for the child(ren) named above no later than thirty days after the issuance of this support 

order. Mother and Father are designated as the Health Insurance Obligor. 

The following applies in ALL CASES: 

During any period after the effective date of this order in which the child(ren) are not 

covered by private health insurance, cash medical support shall be paid in the amount as 

determined by the child support computation worksheets in section 3119.022 or 3119.023 

of the Revised Code, as applicable. Payment of cash medical support shall begin on the first 

day of the month immediately following the month in which private health insurance 

coverage is unavailable or terminates and shall cease on the last day of the month 

immediately preceding the month in which private health insurance coverage begins or 


esumes. The _____________ County Job and Family Services, Child Support Division, 

may change the financial obligations of the parties to pay child support and cash medical 

support in accordance with the terms of this order without a hearing or additional notice to 

the parties. During the period when payment of cash medical support is required, Mother 

and Father shall immediately inform the _____________ County Job and Family Services, 

Child Support Division, when private health insurance coverage for the child(ren) becomes 

available. 

(Fill in each blank with the appropriate percentage.) 

Any health care expenses for the minor child(ren) not paid by insurance shall be 

divided between the parents, with Father paying __________% and Mother paying 

__________%. Health care expenses include, but are not limited to, medical, dental, 

optical, orthodontic, psychological, and pharmaceutical expenses. 

NOTICE TO THE HEALTH INSURANCE OBLIGOR 

Within thirty days of the date of this support order, the Health Insurance Obligor must 

designate the child(ren) as covered dependents under any health insurance policy, contract, 

or plan for which the Health Insurance Obligor contracts. 

Mother and Father are the persons 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). 

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. 

The Health Insurance Obligor(s)’s employer shall release to the other parent, any person 

subject to an order issued under ORC section 3109.19, or the _____________ County Job 

and Family Services, Child Support Division, 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. 

If the person required to obtain private health care insurance coverage for the child(ren) 

subject to this child support order obtains new employment, the agency 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 children in 

private health care insurance coverage provided by the new employer. 

Within thirty days of the date of this support order, the Health Insurance Obligor must 

provide to the other parent 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. 

F. Dependency Exemption for Income Tax Purposes: 

(Select one of the following options by checking the appropriate G.) 


G (Option 1.) G Mother G Father (check the G that applies) shall claim the child(ren) as (a) 

dependent(s) every year. 

G (Option 2.) Mother and Father shall claim the child(ren) as (a) dependent(s) in alternating 

years, with Mother claiming the child(ren) in (check the G that applies) G in odd-numbered years 

G in even-numbered and Father claiming the children in the opposite years. 

G (Option 3.) Mother shall claim ___________________________________ (name of child) as 

(a) dependent(s) and Father shall claim ___________________________________ (name of 

child) as (a) dependent(s). 

G (Option 4.) Other (State who will claim the child(ren) as dependents for income tax purposes.) 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

G. Relocation: 

Neither parent shall relocate his nor her residence without first consulting with the other 

parent and reaching agreement with the other parent as to any modifications to the 

Shared Parenting Plan necessary to accommodate the relocation. 

H. Access to Records: 

Mother and Father shall have equal access to the child(ren)’s records, school activities, and 

daycare center. 

I. Modification and Enforcement: 

Before filing formal court action to enforce or modify the allocation of parental rights and 

responsibilities, including parenting time, Mother and Father shall attempt to resolve 

disputes through mediation. 

J. Other Agreements: 

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We have voluntarily entered into this Shared Parenting Plan and represent to the Court that 

the Plan is in the best interest of our child(ren). We request that the Court adopt this Shared 

Parenting Plan as its allocation of parental rights and responsibilities for our child(ren). 

____________________________________ 

Mother 

Date: _______________________________ 

____________________________________ 

Father 

Date: _______________________________ 



_________________ COUNTY, OHIO 

______________________ DIVISION 

_________________________, * 

Plaintiff, * CASE NO.___________________ 

vs. * 

_________________________, * 

JUDGE______________________ 

Defendant. * ENTRY 

Pursuant to request of the Plaintiff and for good cause shown it is hereby ORDERED that 

the attached Complaint be accepted without pre-payment of the costs. 

____________________________________ 

MAGISTRATE/JUDGE 

Copy: Plaintiff 



_________________ COUNTY, OHIO 

______________________ DIVISION 

_________________________, * 

Plaintiff, * CASE NO.____________________ 

vs. * 

_________________________, * 

JUDGE ______________________ 

Defendant. * ENTRY 

This cause came on the parties’ Agreed Complaint to Allocate Parental Rights 

and Responsibilities and Establish Shared Parenting regarding the parties’ minor children. 

The Court finds that the parties have reached an agreement on all issues relating 

to the parties’ minor children, the terms of which are incorporated into the attached Shared 

Parenting Plan. 

The Court finds that the attached Shared Parenting Plan is in the best interests of 

the parties’ minor children, approves it and incorporates the same as if fully rewritten herein and 

ORDERS the parties to comply with the terms of the same. 

____________________________________ 

JUDGE 


IN THE COURT OF COMMON PLEAS OF ____________________ COUNTY, OHIO 

__________________________________ COURT 

Plaintiff / Petitioner 

Case No. 

v. Judge _________________________________ 

Defendant / Petitioner 

INFORMATION FOR CHILD CUSTODY 

PROCEEDING 

(§3127.73 Ohio Rev. Code) 

NOTE: By law, an affidavit must be filed and served with the first pleading filed by each party in every child custody proceeding 

(allocation of parental rights, legal custody, parenting time, or visitation). Each party has a continuing duty while this case is pending 

to inform the Court of any child custody proceeding concerning the child(ren) in any other court in this or any other state. If more 

space is needed, attach an additional page. 

My full name is 

and I state, under oath, that the following information is true: 

1. State the name and date of birth for each child who is in issue in this case, the address(es) where each child lived during the past five 

years, the dates the child lived at each address, and the name of all adults who lived with the child at each address. (If more than 

four children are in issue, attach a separate page and provide this same information for each additional child.) 

Child’s Name: 

Date of Birth: 

Last Five (5) Years Address Adult(s) who lived at this address 

to 





Present 




to Present 






















2. The names and current addresses of all adults listed in #1 are: 

Adult’s Name 

Current Address 

3. Have you participated as a party, a witness, or in any other capacity in any other proceeding concerning the allocation of parental 

rights and responsibilities for these child(ren), including any proceeding concerning parenting time rights, visitation, or the 

designation of residential parent and legal custodian? 

Yes. 

No. 

If you answer “Yes”, state the name and address of the court, the case number, and the date of the proceeding. 

4. Do you know of any other proceeding that could affect the current proceeding, including a proceeding for enforcement of a child 

custody determination, a proceeding relating to domestic violence or protection orders, a proceeding to adjudicate the child as an 

abused, neglected, or dependent child, a proceeding seeking termination of parental rights, or a proceeding for adoption? 

Yes. 

No. 

If you answer “Yes”, state the name and address of the court or agency, the case number, and the nature of the proceeding. 


5. Do you know of any person who is not a party to this proceeding and who has physical custody of the child(ren), claims to be the 

residential parent and legal custodian of the child(ren), or claims to have parenting time or visitation rights with respect to the 

child(ren)? 

Yes. 

No. 

6. Do you know of any child support order for the child(ren) that has been issued by any court or agency? 

Yes. 

No. 

If your answer is “Yes”, state the name and address of the court or agency that issued the order and the case number. 

7. I understand that I must inform the Court if I learn of any other child custody proceeding concerning the child(ren) that could affect 

the current proceeding. 

OATH OF AFFIANT 

I hereby swear or affirm that the answers above are true, complete, and accurate to the best of my knowledge. I understand that 

falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, 

and that falsification of this document may also subject me to criminal penalties for perjury under Ohio Revised Code 2921.11. 

______________________________________ 

AFFIANT 

Sworn to and subscribed before me on this _____ day of __________________, __________. 

________________________________________________ 

NOTARY PUBLIC 


APPLICATION FOR CHILD SUPPORT SERVICES 

NON-PUBLIC ASSISTANCE APPLICANT 

IMPORTANT: If you are receiving ADC or Medicaid, do not complete this application, because you became eligible for child support services when you became eligible to receive ADC 

or Medicaid. 

I the undersigned,__________________________________________________, request Child Support Services from the _________________________ County Child Support Enforcement 

Agency. I understand and agree to the following conditions: 

A. I am a resident of the County in which services are requested. 

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

The Child Support Enforcement Agency can assist you in providing the following services: 

1. Location of Absent Parents. 

The agency can assist in finding where an absent parent is currently living, in what city, town or state. The applicant can request “Location Services 

Only:, if the sole need is to find the whereabouts of the absent parent. 

2. Establishment or M odification of Child Support and M edical Support. 

The CSEA can assist you to obtain an order for support if you are separated, have been deserted or need to establish paternity (fatherhood). The CSEA can 

also assist you in changing the amount of support orders (modification), and to obtain medical support. 

3. Enforcement of Existing Orders. 

The CSEA can help you collect current and back child support. 

4. Federal and State Income Tax Offset Submittals for the Collection of Child Support Arrearages. 

The agency can collect back support (arrearages) by intercepting a non-payor’s federal and state income tax refunds on some cases. 

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

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

6. Establishment of Paternity. 

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

may request paternity services. 

7. Collection and Disbursement of Payments. 

The CSEA can collect the child support for you, and send you a check for the amount of the payments received. Back support collected will be paid to you 

until all of the back support you are owed is paid. 

8. Interstate Collection of Child Support. 

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

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

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. 

APPLICANT INFORMATION (INFORMATION ABOUT YOU) 

Name 

Date of Birth 

Social Security Number (SSN) 

Current Marital Status (Check One) 

G Single G Married G Divorced G Separated 

G Deserted G Widowed 

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 a written notice to inform me if my case has been 

accepted for child support services (IV-D Services.) 

Signature of Applicant 

Date 

JFS 07076 (Rev. 5/2001) 

(Formerly DHS 7076) 

Title IV-D Application 


Applicant’s Name (Last, First, Middle) 

Address (Street/Route, P.O. Box) 

Telephone Number (Home) 

(Work) 

City, State, Zip Code 

INFORMATION ON CHILDREN 

Child 1 Child 2 Child 3 Child 4 

a. Name 

b. Sex 

c. SSN 

d. Date of Birth (DOB) 

e. Name(s) of Absent Parent 

f. Has Paternity (Fatherhood) 

Been Established? 

g. Is There An Order for Support 

ABSENT PARENT INFORMATION OR PARENT ORDERED TO PAY CHILD SUPPORT 

Absent Parent #1 Absent Parent #2 Absent Parent #3 

Name 

Address 

SSN 

Date of Birth (DOB) 

Name of Employer 

Address of Employer 

Amount of Support Ordered 

Case Number on Support Order 

Date of Support Order 

Location Where Order Was Issued 

Military Service 

Arrest Record: Give Date and Place 

If the absent parent has been on Public 

Give Name and Address of Current 

• Have you ever been on Public Assistance? Yes No 

When (Date) Where (City and State) County 

FOR AGENCY USE ONLY 

Case Name Date Requested Date Mailed or Provided 

Case Number 

Date Returned or File Date 

JFS 07076 (Rev. 5/2001) 

(Formerly DHS 7076) 

Title IV-D Application 


APPENDIX E 

Instructions for Completing 

Financial Disclosure/Affidavit of Indigency 

Form OPD-206R 

The following instructions are for the Financial Disclosure/Affidavit of Indigency form (OPD-206R). The form is 

divided into ten sections, I-X. For the purpose of these instructions, spaces requiring an entry have been 

numbered. 

I. PERSONAL INFORMATION 

(1)Enter the name of the applicant. 

TO BE COMPLETED BY THE APPLICANT 

(2)Enter the Social Security number for which representation is being provided. 

(3)Enter the date of birth of the applicant. Use the format Month/Day/Year. 

(4)Enter the street address where the applicant receives mail. Include P.O. Box number, street 

number, and apartment number where applicable, as well as the city, state, and zip code. 

(5)Enter the home telephone number of the applicant. If there is no home telephone, write “none” in 

this space. 

(6)Enter the residential address of the applicant if it is different from the mailing address. If the mailing 

address and the residential address are the same, leave this space blank. 

(7)Enter the number of a telephone where the applicant may receive messages within 48 hours after 

the caller leaves them. This is especially important if there is no home telephone. There must be a 

way for the courts and the appointed attorney(s) to contact the applicant by telephone if necessary. 

II. OTHER PERSONS LIVING IN HOUSEHOLD 

(8)Enter the names of other persons living in the applicant’s household. These other persons may 

include children and other dependents as well as other financially contributing members of the 

household. 

(9)Enter the ages of the other persons living in the applicant’s household. 

(10) Enter the relationship to the applicant of the other persons living in the household. For example, 

to indicate the relationship of a female child of the applicant, this space should read “daughter,” 

not “father” or “mother.” 

If there are more than four other persons living in the applicant’s household, attach additional sheet that 

provides the same information for those not listed on the form. 

III. MONTHLY INCOME / EMPLOYMENT 

For each type of income, the applicant must enter their own earnings in the “Self” column, the spouse’s 

earnings in the “Spouse” column, and the total earnings of other financially contributing persons living 

in the household in the “Household Members” column. In the “Total” column, enter the total income 

from each type by adding the amounts across each row. 

List monthly income figures for the following: 


APPENDIX E 

(11) Earnings or wages before taxes. 

(12) Unemployment compensation received. 

(13) Workers’ compensation received. 

(14) Pension benefits received. 

(15) Social security benefits received. 

(16) Child support received from a parent not living in the household. Do not include ADC in the 

calculation of this amount. 

(17) Works First/TANF. 

(18) Disability pay. 

(19) Any other income source. Note: Food stamps can no longer be considered as income. 51 

USC 2107 (b). 

(20) Any other income source. 

(21) Enter the total income for the household by adding together the amounts in the “Total” column. 

(22) Enter the name of the applicant’s employer and the name(s) of the employer(s) of any other 

employed household member(s). 

(23) Enter the address and phone number of the employer(s). 

IV. ALLOWABLE MONTHLY EXPENSES 

List monthly household expenses for the following: 

(24) Child support actually paid for children not residing in the applicant’s household. 

(25) Child care. This expense may not be claimed if any adult member of the applicant’s household is 

unemployed. 

(26) Transportation to and from work. This may include bus fare or gasoline and parking expenses, 

but not auto insurance or repairs. 

(27) All types of insurance. This should include medical, dental, life, homeowners insurance, renters 

insurance, automobile insurance, etc. 

(28) Health and dental care that is over and above the amount paid for medical and dental insurance. 

This may include prescription medications, co-payments, the payment of deductibles, etc. 

(29) Medical expenses and other expenses incurred in caring for sick or injured family members. 

(30) Enter the total of monthly expenses by adding together the entries in the “Amount” column. 

V. TOTAL INCOME 

(31) Enter the amount shown at “Subtotal A,” the space identified in these instructions as number (20). 


APPENDIX E 

(32) Enter the amount shown at “Subtotal B,” the space identified in these instructions as number (30). 

(33) Enter the total monthly income at “Grand Total C” by subtracting the amount in space (32) from 

the amount in space (31). 

VI. ASSET INFORMATION 

For each “Type of Asset” listed in this section, the applicant must describe the item(s) in the center 

column including length of ownership and the make, model, and year of the asset whenever applicable, 

and indicate the value of that item in the “Estimated Value” column. The following instructions clarify 

the types of assets about which information is requested. 

(34) “Real Estate/Home” includes any and all property and buildings owned or mortgaged by the 

applicant. The description of the property or buildings should include the length of ownership. 

The estimated current market value of the property or buildings should be entered in the 

“Estimated Value” column. 

(35) List the total of all “Stocks/Bonds/CD’s” owned by the applicant. 

(36) “Automobiles” includes cars only. 

(37) “Trucks/Boats/Motorcycles” includes any type of mechanically powered vehicle other than cars 

used for transportation. 

(38) Other Valuable Property may include precious metals and/or stones, works of art, valuable 

collections, electronic equipment, farm equipment, etc. This category does not include home 

furnishings and clothing. 

(39) “Cash on Hand” includes any U.S. currency immediately available to the applicant. 

(40) “Money owed to applicant” includes tax refunds, anticipated dividends, or any accounts payable 

expected from an individual or an organization for which agreed upon services or goods were 

provided by the applicant for an agreed upon price. 

(41) “Other” refers to any other type of asset owned by the applicant to which a dollar value can be 

attached. 

(42) Enter the name of the bank at which the checking account is held, the account number, and the 

current balance of the checking account. 

(43) Enter the name of the bank at which the savings account is held, the account number, and the 

current balance of the savings account. 

(44) Enter the name of the credit union at which an account is held, the account number, and the 

current balance of the account. 

(45) Enter the “Grand Total” of the applicant’s assets by adding together the amounts entered in the 

“Estimated Value” column. 

VII. MONTHLY LIABILITIES ‘ OTHER EXPENSES 

The applicant must enter the monthly amount of each “Type of Liability” listed in this section. The 

following instructions clarify the liabilities about which information is requested. 


APPENDIX E 

(46) “Rent/Mortgage” refers to any payment made for living quarters. The total amount paid must be 

entered in this space. 

(47) “Food” refers to the amount spent on food by the applicant’s household. The dollar value of food 

purchased with food stamps should be included in the amount entered. 

(48) “Electric” refers to the cost of electricity purchased from a regulated electricity provider. If the 

cost of electricity is included in the monthly rent, no dollar amount should be entered here. 

(49) “Gas” refers to the cost of natural gas or L.P. gas purchased from a regulated natural gas or L.P. 

gas provider. If this cost is included in the monthly rent, no dollar amount should be entered 

here. 

(50) “Fuel” refers to the cost of gasoline purchased for purposes other than transportation to and from 

work, plus the amount of other fuels purchased for other necessary reasons such as heating and 

the operation of farm machinery. 

(51) “Telephone” refers to the cost of all local and long distance telephone calls. 

(52) “Cable” refers to the cost of cable television service. 

(53) “Water/Sewer/Trash” refers to the cost of each of these services. If the applicant is not billed 

directly for one or more of these services, no dollar amount should be entered here. 

(54) “Credit Cards” refers to the total of the minimum monthly payments currently owed on all major 

credit cards, department store cards, or independent credit cards held by the applicant. 

(55) “Loans” refers to the total monthly payments on all loans including student loans, automobile 

loans, and loans for other purposes. Home mortgages are not to be included in this category. 

(56) “Taxes Owed” refers to the monthly amount of federal, state, and local taxes owed by the 

applicant. These include current taxes withheld by the employer as well as past tax debt that is 

currently being repaid. 

(57) “Other” refers to any other regular monthly expenditure (e.g. education for children or self, rent-toown 

items, etc.). 

(58) Enter the “Grand Total E” by adding together all the liabilities and other expenses in the section. 

VIII. GRAND TOTALS 

(59) Enter the “Total Monthly Income.” This is the same number found at “Grand Total C,” or number 

(33) of these instructions. 

(60) Enter the “Total Assets.” This is the same number found at “Grand Total D,” or number (45) of 

these instructions. 

(61) Enter the “Total Monthly Liabilities/Other Expenses.” This is the same amount found at “Grand 

Total E,” or number (61) of these instructions. 

IX. AFFIDAVIT OF INDIGENCY 

(62) Print or type the name of the applicant. 


APPENDIX E 

(63) Enter the signature of the applicant and the date of signature as witnesses by a notary public. 

TO BE COMPLETED BY A NOTARY PUBLIC 

(64-65) Enter the date the signing of the affidavit was witnessed. 

(66) Enter the county in which the signing of the affidavit was witnessed. 

(67) Enter the state in which the signing of the affidavit was witnessed. 

(68) The notary public must sign and stamp the form. 

TO BE COMPLETED BY THE JUDGE 

X. JUDGE CERTIFICATION 

This section of the form should only be completed if the applicant is unable to fill out the financial 

disclosure form and/or sign the affidavit of indigency. In such a case, the judge may indicate by his or 

her signature that the applicant is indeed indigent. 

(69) List the reason the client is unable to sign the form. 

(70) The judge must sign any form that cannot be properly completed by the applicant. 


FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY 


Name SS# D.O.B. 

Mailing Address City State Zip Phone 

Residence (if different from above) 

Message Phone (within 48 hours) 


Name Age Relationship Name Age Relationship 


III. MONTHLY INCOME/EMPLOYMENT INFORMATION 

Type of Income Self Spouse Household Members Total 

Employment (Gross) (11) 

Unemployment (12) 

Worker’s Comp. (13) 

Pension (14) 

Social Security (15) 

Child Support (16) 

Works First/TANF (17) 

Disability (18) 

Other (19) 

Other (20) 

Employer’s Name (for all household members)(22) SUBTOTAL A (21) 

Address 

Phone 


Type of Expense 

Amount 

Child Support Paid Out (24) 

Child Care (if working only) (25) 

Transportation for Work (26) 


Total Monthly Income - Total Allowable Expenses = Total Income 

Insurance (27) SUBTOTAL A (31) 

Medical/Dental (28) - SUBTOTAL B (32) 

Medical & Associated Costs 

of Caring for Infirm Family 

Members (29) 

GRAND TOTAL C (33) 

SUBTOTAL B (30) 


Type of Asset Describe/Length of Ownership/Make, Model, Year (Where applicable) Estimated Value 

Real Estate/Home Price:$ Date Purchased: (34) Equity: 

Stocks/Bonds/CD’s (35) 

S A M P 

Automobiles (36) 

Trucks/Boats/Motorcycles (37) 

Other Valuable Property (38) 

Cash on Hand (39) 

Money Owed to Applicant (40) 

Other (41) 

Checking Acct. (Bank/Acct. #) (42) 

Savings Acct. (Bank/Acct. #) (43) 

Credit Union (Name/Acct.#) (44) 

GRAND TOTAL D (45) 


VII. MONTHLY LIABILITIES/OTHER EXPENSES 

Type of Liability 

Amount 

VII. GRAND TOTALS 

Rent/Mortgage (46) Grand Total C 

Food (47) Total Monthly Income (59) 

Electric (48) 

Gas (49) 

Fuel (50) Grand Total D 

Telephone (51) Total Assets (60) 

Cable (52) 

Water/Sewer/Trash (53) 

Credit Cards (54) 

Loans (55) Grand Total E 

Taxes Owed (56) Total Monthly Liabilities 

Other (57) 

and Other Expenses 

GRAND TOTAL E (58) 


I, ____________________(62)________________________ 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 my attorney if my financial situation should change before the 

disposition of my case. 

3. I understand that it if is determined by the county, or by the Court, that legal representation was 

provided for me to which I was not entitled, 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 from 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 

Section 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. 

X. JUDGE/ATTORNEY CERTIFICATION 

S A M P 

(61) 

________________________(63)_______________________ 

Client Signature 

Date 

Notary Public: 

Subscribed and duly sworn before me according to law, by the above named applicant this __(64)__ day of 

______(65)______, _______ , County of ________(66)_________ and State of _______(67)_______. 

________________________(68)______________________ 

Notary Signature 

I hereby certify that the above-noted client is unable to fill out and/or sign this financial disclosure/affidavit for the 

following reason: _______________________________(69)_________________________________________. 

I have determined that the applicant meets the criteria for receiving court appointed counsel. 

___________________________(70)_________________________ 

Judge/Attorney Signature 

Date 


FINANCIAL DISCLOSURE/AFFIDAVIT OF INDIGENCY 


Name SS# D.O.B. 

Mailing Address City State Zip Phone 

Residence (if different from above) 

Message Phone (within 48 hours) 




III. MONTHLY INCOME/EMPLOYMENT INFORMATION 

Type of Income Self Spouse Household Members Total 

Employment (Gross) 

Unemployment 

Worker’s Comp. 

Pension 

Social Security 

Child Support 

Works First/TANF 

Disability 

Other 

Other 

Employer’s Name (for all household members) 

Address 

SUBTOTAL A 

Phone 


Type of Expense 

Amount 

Child Support Paid Out 

Child Care (if working only) 

Transportation for Work 

Insurance SUBTOTAL A 

Medical/Dental 

Medical & Associated Costs 

of Caring for Infirm Family 

Members 


Total Monthly Income - Total Allowable Expenses = Total Income 

- SUBTOTAL B 

GRAND TOTAL C 

SUBTOTAL B 


Type of Asset Describe/Length of Ownership/Make, Model, Year (Where applicable) Estimated Value 

Real Estate/Home Price:$ Date Purchased: Equity: 

Stocks/Bonds/CD’s 

Automobiles 

Trucks/Boats/Motorcycles 

Other Valuable Property 

Cash on Hand 

Money Owed to Applicant 

Other 

Checking Acct. (Bank/Acct. #) 

Savings Acct. (Bank/Acct. #) 

Credit Union (Name/Acct.#) 

GRAND TOTAL D 


VII. MONTHLY LIABILITIES/OTHER EXPENSES 

Type of Liability 

Amount 

Rent/Mortgage 

Food 

Electric 

Gas 

Fuel 

Telephone 

Cable 

Water/Sewer/Trash 

Credit Cards 

Loans 

Taxes Owed 

Other 

Total Monthly Income 

Total Assets 

Total Monthly Liabilities 

and Other Expenses 

VII. GRAND TOTALS 

Grand Total C 

Grand Total D 

Grand Total E 

GRAND TOTAL E 


I, ____________________________________________ 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 my attorney if my financial situation should change before the 

disposition of my case. 

3. I understand that it if is determined by the county, or by the Court, that legal representation was 

provided for me to which I was not entitled, 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 from 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. 

__________________________________________________ 

Client Signature 

Date 

Notary Public: 

Subscribed and duly sworn before me according to law, by the above named applicant this _______ day of 

______________, _______, County of ___________________ and State of ___________________. 

__________________________________________________ 

Notary Signature 

X. JUDGE/ATTORNEY CERTIFICATION 

I hereby certify that the above-noted client 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/Attorney Signature 

Date

custody agreed complaint to allocate parental rights ...

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