COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
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Plaintiff/Petitioner 1	:	Case No.
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Street Address	:
:	Judge
City, State and Zip Code	:
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vs./and	:	Magistrate
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Defendant/Petitioner 2	:
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Street Address	:
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City, State and Zip Code	:
Instructions: The Parenting Time Schedule must be attached to this Plan. Parents are urged to consult the Planning for Parenting Time Guide: Ohio’s Guide for Parents Living Apart available at http://www.supremecourt.ohio.gov/Publications/JCS/parentingGuide.pdf.
PARENTING PLAN - NO PRIVATE INSURANCE
We, the parents, “(name) Plaintiff/Petitioner 1”, and ,“ (other parent’s name) Defendant/Petitioner 2”, have (number) child(ren) from the marriage or relationship. Of the child(ren), (number) is/are emancipated adult(s) and not under any disability, and the following (number) child(ren) are minor child(ren) and/or mentally or physically disabled child(ren) incapable of supporting or maintaining themselves (name and date of birth of each child):
The parents agree to the care, parenting, and control of their child(ren) as provided in this Parenting Plan.
FIRST: PARENTS’ RIGHTS
We, the parents, shall have, unless limited:
A.	The right to reasonable telephone contact with the child(ren) when they are with the other parent.
B.	The right to be notified in case of an injury to or illness of the minor child(ren).
C.	The right to inspect and receive the minor child(ren)’s medical and dental records and the right
to consult with any treating physician, dentist and/or other health care provider, including but not
limited to psychologists and psychiatrists.
D.	The right to consult with school officials concerning the minor child(ren)'s welfare and educational
status, and the right to inspect and receive the child(ren)’s student records to the extent permitted
by law.
E.	The right to receive copies of all school reports, calendars of school events, notices of parent-
teacher conferences, and school programs.
F.	The right to attend and participate in parent-teacher conferences, school trips, school programs,
and other school activities in which parents are invited to participate.
G.	The right to attend and participate with the child(ren) in athletic programs and other extracurricular
activities.
SECOND: ALLOCATION OF PARENTAL RIGHTS AND RESPONSIBILITIES
A.	General Responsibilities
Each parent shall take all measures necessary to foster respect and affection between the
child(ren) and the other parent. Neither parent shall do anything that may estrange the child(ren)
from the other parent, or impair the child(ren)’s high regard for the other parent.
B.	Medical Responsibilities
The parents shall notify the other parent promptly if a child experiences a serious injury, has a
serious or chronic illness, or receives treatment in an emergency room or hospital. The notification
shall include the emergency, the child's status, locale, and any other pertinent information
as soon as practical, but in any event within 24 hours.
The parents shall consult with each other about the minor child(ren)’s medical care needs
and the residential parent shall immediately notify the other parent about all major non- emergency
medical decisions before authorizing a course of treatment. Parents have a right to know the
necessity for treatment, proposed cost, and proposed payment schedule. Each parent may also
secure an independent evaluation at the parent’s expense to determine the necessity for treatment.
If the parties cannot agree regarding a course of treatment, the residential parent’s decision shall
control. The parents shall provide the other with the names and telephone numbers of all health
care providers for the child(ren).
C.	Residential Parent and Legal Custodian
Plaintiff/Petitioner 1 shall be the residential parent and legal custodian of the following child(ren):
Defendant/Petitioner 2 shall be the residential parent and legal custodian of the following child(ren):
D.	Parenting Time Schedule
Unless otherwise agreed, the parents shall have parenting time with the child(ren) according to the
attached Parenting Time Schedule that shows the times that the child(ren) shall be with each
parent on weekdays, weekends, holidays, and vacation times.
(The Parenting Time Schedule must be attached to this Plan.)
E.	Transportation (select one):
Each parent shall be responsible for providing transportation for the child(ren) at the beginning
of the parent’s parenting period. Each parent shall be responsible for providing transportation for the
child(ren) to and from school and activities during the parent’s parenting period.
We agree to the following arrangements for providing transportation for our child(ren) at the
beginning, during, or end of a parenting period:
F.	Current Address and Telephone Number
Plaintiff’s/Petitioner 1’s current home address and telephone number, including cellular telephone number:
Defendant’s/Petitioner 2’s current home address and telephone number, including cellular telephone number:
G.	Relocation Notice
Pursuant to section 3109.051(G) of the Revised Code:
If the residential parent intends to move to a residence other than the residence specified in the
court order, the parent shall file a notice of intent to relocate with this Court. Except as provided
in divisions (G)(2), (3), and (4) of section 3109.051 of the Revised Code, the Court shall send a copy
of the notice to the parent who is not the residential parent. Upon receipt of the notice, the Court, on
its own motion or the motion of the parent who is not the residential parent, may schedule a hearing
with notice to both parents to determine whether it is in the best interests of the child(ren) to revise
the parenting time schedule for the child(ren).
The non-residential parent shall inform in writing the Court and the other parent of changes
in address and telephone, including cellular telephone number, unless otherwise provided by court
order.
The relocation notice must be filed with the Court granting the allocation of parental rights
and responsibilities (name and address of the Court):
H.	Records Access Notice
Pursuant to sections 3109.051(H) and 3319.321(B)(5)(a) of the Revised Code:
Subject to sections 3125.16 and 3319.321(F) of the Revised Code, the parent who is not the
residential parent is entitled to access to any record that is related to the child(ren), and to which
the residential parent is legally provided access under the same terms and conditions as the
residential parent. Any keeper of a record who knowingly fails to comply with any record access
order is in contempt of court.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding records access are as follows:
I.	Day Care Access Notice
Pursuant to section 3109.051(I) of the Revised Code:
In accordance with section 5104.11 of the Revised Code, the parent who is not the residential
parent is entitled to access to any day care center that is or will be attended by the child(ren)
with whom parenting time is granted, to the same extent that the residential parent is granted
access to the center.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding day care access are as follows:
J.	School Activities Access Notice
Pursuant to section 3109.051(J) of the Revised Code:
Subject to section 3319.321(F), the parent who is not the residential parent is entitled to access
to any student activity that is related to the child(ren) and to which the residential parent is legally
provided access, under the same terms and conditions as the residential parent. Any school
employee or official who knowingly fails to comply with this school activities access order is in
contempt of court.
Restrictions or limitations:
None
Restrictions or limitations to non-residential parents regarding school activities access are as
follows:

THIRD: CHILD SUPPORT - NO PRIVATE INSURANCE AVAILABLE
The Obligor pays child support and the Obligee receives child support.
is the Child Support Obligor.	is the Child Support Obligee.
The full name and date of birth of each child subject to this child support order includes the following:
Private health insurance through a group policy, contract, or plan is not available for the child(ren) at
a reasonable cost and such insurance is not being provided in accordance with R.C. 3119.302(A)(2).
Based upon the evidence presented to the Court and The Child Support Worksheet attached hereto
and incorporated herein, the Court finds that it is in the best interest of the parties’ child(ren) that
effective	, the Obligor,	will pay child
support to	, the Obligee, payable through The Office of Child Support of
The Department of Job and Family Services for the parties’ child(ren) as follows:

Current child support per month, per child (before processing fee)	$
Combined current child support (before processing fee)	$
Current cash medical support obligation per month, per child (before processing fee)	$
Combined cash medical support (before processing fee) **	$
Child support arrearage payment per month (before processing fee)	$
2% Processing Fee on TOTAL monthly order	$
TOTAL MONTHLY ORDER:	$

Deviation (SELECT only the applicable paragraphs):
a.	The Child Support Obligor’s obligation for child support is deviated by
AND/OR the Child Support Obligor’s cash medical support obligation is deviated by
.	The Obligor’s child support AND/OR [circle appropriate choice] cash
medical support obligation(s) deviate(s) from the actual annual obligation on the child support
worksheet attached hereto because, pursuant to R.C. 3119.23 (A) through (Q), the actual annual
obligation is unjust, inappropriate and not in the best interest of the child(ren) for the following
reasons: [INSERT deviation factor(s) here pursuant to R.C. 3119.23 (A)-(Q)].
AND/OR (which may be in addition to factors considered pursuant to R.C. 3119.23(A)-(Q))
b.	The Child Support Obligor has parenting time ordered by the Court that equals or exceeds
90 overnights per year and is entitled to a 10% reduction as identified on Line 24 of the attached
Child Support Worksheet, pursuant to R.C. 3119.231(A);
OR
The Child Support Obligor has parenting time ordered by the Court that equals or exceeds
147 overnights per year and the Court has determined the deviation for Obligor’s parenting time
shall be	as shown on Line 24 of the attached Child Support Worksheet,
pursuant to R.C. 3119.23(B).
OR
c.	The Child Support Obligor’s obligation for child support and cash medical support do not
deviate from the actual annual obligation on the child support worksheet attached hereto.
[If there is NO deviation and over 90/147 overnights for the Obligor, pursuant to R.C.
3119.23 identify the facts that are the basis for a deviation not being granted]:
Any credit or arrearage of child support or spousal support on the Child Support Enforcement Agency
(CSEA) records is preserved.
Notwithstanding Section 3109.01 of the Revised Code, the parental duty of support to children,
including the duty of a parent to pay support pursuant to a child support order shall continue beyond
the child's eighteenth birthday only in accordance with Section 3119.86 of the Revised Code. The
duty of support shall continue during seasonal vacations. Child Support Obligor is responsible for
making payments directly to The Office of Child Support of The Department of Job and Family
Services until such time as a deduction order takes effect. Any payment made directly to the Child
Support Obligee and not through The Office of Child Support of The Department of Job and Family
Services shall be deemed a gift and not credited to the support account.
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 Chapters 3119, 3121, 3123, and 3125 of the Revised Code or a withdrawal directive
issued pursuant to sections 3123.24 to 3123.38 of the Revised Code and shall be forwarded to the
Child Support Obligee in accordance with Chapters 3119, 3121, 3123 and 3125 of the Revised Code.
A person and/or entity required to comply with withholding or deduction notices described in Section
3121.03 of the Revised Code shall determine the manner of withholding or deducting from the
specific requirement included in the notices without the need for any amendment to the support
order, and a person required to comply with an order described in sections 3121.03, 3121.04 to
3121.06 and 3121.12 of the Revised Code shall comply without need for any amendment to the
support order. The withholding or deduction noticed and other orders issued under sections 3121.03,
3121.04 to 3121.06 and 3121.12 of the Revised Code, and the notices that require the obligor to
notify the Child Support Enforcement Agency administering the support order of any change in the
obligor’s employment status or of any other change in the status of the obligor’s assets, are final and
enforceable by the Court.
Payments to Child Support Payment Central (“CSPC”) must be sent to the following address: Ohio
CSPC, P. O. Box 182372, Columbus, Ohio 43218-2372. Payments may be made by personal check,
certified check, cashier’s check, or money order. The payment must include the Court case number
and the SETS number	.	If the SETS number is not
available, then the payment must include Obligor’s Social Security number.
Regardless of the frequency or amount of the support payments, The Office of Child Support of The
Department of Job and Family Services will administer the order on a monthly basis in accordance
with R.C. 3121.51 to 3121.54. Payments must be made as ordered by the Court.
The Obligee must notify The Child Support Enforcement Agency immediately and the Obligor may
notify The Child Support Enforcement Agency of any reason to terminate the support order. A willful
failure to notify The Child Support Enforcement Agency is contempt of court. Reasons include but are
not limited to the following: a). the child turns 18 years old and no longer attends an accredited
high school on a full-time basis, if the support order does not require support to continue past age 18;
b). the child’s death, marriage, emancipation, or enlistment in the armed services; or c). the change
of legal custody of the child.
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 OR OBLIGEE AND YOU FAIL TO GIVE THE REQUIRED NOTICES TO
THE CHILD SUPPORT ENFORCEMENT AGENCY, YOU MAY NOT RECEIVE NOTICE OF THE
CHANGES AND REQUESTS TO CHANGE THE CHILD SUPPORT AMOUNT, HEALTH CARE
PROVISIONS, OR TERMINATION OF THE CHILD SUPPORT ORDER. 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.
Definitions: Applicable to Health Expenses and Health Insurance
“Cash Medical.” At this time, the State of Ohio recognizes that parents spend an average of $388.70
per year, per child on uncovered health care expenses. Therefore, the term “cash medical” is defined
as$388.70 per child, per year (as amended by statute), and the responsibility for paying this expense
is allocated between the parents by income shares, as identified on Line 23 of the child support
worksheet.
“Cash medical support” means a dollar amount ordered to be paid in a child support order towards
“ordinary medical expenses” incurred on behalf of the children identified in the parties’ child support
order during a calendar year. The child support recipient’s share (Obligee) remains in his/her
household, while the child support payor’s share (Obligor) is paid to the Obligee in conjunction with
the child support amount ordered, ** unless the child is receiving government provided
healthcare at no cost to either parent.
“Ordinary medical expenses” include copayments, deductibles and uninsured/unreimbursed medical-
related costs for the children named in the child support order.
“Extraordinary medical expenses” include any uninsured/unreimbursed medical-related costs
Incurred for a child named in the child support order that exceed the total cash medical support
amount, including the monthly amount that is Obligee’s share, as identified on line 28 of the child
support worksheet.
“Reasonable cost for health insurance” means that a plan of health insurance for the child(ren)
identified in the child support order is accessible to the parent ordered to provide health insurance
coverage at a cost of 5% or less of his/her gross annual income (identified as the “Health Insurance
Maximum” on line 8 of the child support worksheet), unless: (a) one or both parties expressly agree
to provide such health insurance for the children at a cost exceeding 5% of his/her gross income; or
(b) the Court finds that it is in the best interest of the parties’ child(ren) for one or both parents to
provide such insurance at a cost exceeding 5% of his/her gross income as such insurance coverage
will not impose an undue financial burden on the parent(s).
Provision of Health Insurance for the Child(ren)
Neither parent has health insurance accessible and available at a reasonable cost for the benefit of
the minor child(ren). In the event that private health insurance becomes available and accessible to
either parent, at a reasonable cost, the parent to whom such insurance becomes available shall
obtain such private health insurance for the child(ren) no later than 30 days after it becomes
available to him or her, at a reasonable cost. The parent obtaining such insurance for the
child(ren) must inform the Child Support Enforcement Agency when private health insurance
coverage for the child(ren) has been obtained. A Shared Liability Order shall issue.
This Order shall remain in effect for each child identified in the parties’ child support order until each
such child reaches the age of eighteen (18) and no longer attends an accredited high school on a
full-time basis unless otherwise ordered. Except in cases in which a child support order requires the
duty of support to continue for any period after the child reaches age nineteen, the order shall not
remain in effect after the child reaches age nineteen.
Payment of Uninsured/Unreimbursed Extraordinary Medical Expenses
Both parents are liable to all health care providers for their child(ren)’s uncovered extraordinary
health care expenses as defined herein according to the formula set forth below.
The Child Support Obligee (recipient of child support),	is
responsible for paying the first $388.70 per year, per child for the child(ren)’s uninsured/unreimbursed
health care expenses (This amount will be modified if there is a deviation in cash medical
support, to correspond with the amount of the deviation as identified on lines 27 and 28 of the
child support worksheet. A 100% deviation will result in the parents paying all uncovered
health expenses proportionally, as all such expenses would be “extraordinary.” Obligee
should only be responsible for paying a certain amount, per year, per child, if that amount is
paid as cash medical support (amount will include both parties’ shares).
The remaining costs of any and all uninsured/unreimbursed medical, dental, orthodontic, optical,
prescription, psychological, counseling or psychiatric expenses, including deductibles and/or
co-payments under the health insurance plan for the child(ren), shall be paid	% by the
Child Support Obligor,	and	% by the Child Support Obligee,
.	Each parent must submit to the other parent copies of all medical bills and
receipts for payment as soon as each parent is in receipt of the bill/receipt. Each parent must submit
copies of all bills (including expenses for which the submitting parent is responsible) so the other
parent is aware of what expenses have been incurred and what expenses have been paid. Each
parent should have a complete set of all the medical bills and receipts. Documentation of all such
expenses shall be provided to the other parent and reconciliation of the amounts owed for
reimbursement shall occur on a quarterly basis (the last day of January, April, July, and November
each year).
If one parent has paid the bill in full, the other parent must pay his/her share to the parent who paid
the bill within 30 days after he/she receives the receipts. If the health care provider has not been
paid in full, each parent must make arrangements with the health care provider to pay his/her share
within 30 days of the date that he/she receives the bill. If the bill is later reduced for any reason
(insurance payment, insurance company modification, etc.), the parent who first learns of the
reduction must notify the other parent immediately. Each parent’s portion of the original bill will be
reduced accordingly, based on the percentage of each parent’s responsibility for the original bill.
Neither parent may use the child(ren) to deliver medical bills, proof of payment, or reimbursement to
to the other parent.
FOURTH: TAX EXEMPTIONS
Income tax dependency exemptions (check all that apply):
A.	The Plaintiff/Petitioner 1 shall be entitled to claim the following minor child(ren) for all tax
purposes for even-numbered tax years odd-numbered tax years all eligible tax years, so
long as Plaintiff/Petitioner 1 is substantially current in any child support Plaintiff/Petitioner 1 is
required to pay as of December 31 of the tax year in question:
The Defendant/Petitioner 2 shall be entitled to claim the following minor child(ren) for all tax
purposes for even-numbered tax years odd-numbered tax years all eligible tax years, so
long as Defendant/Petitioner 2 is substantially current in any child support Defendant/Petitioner 2 is
required to pay as of December 31 of the tax year in question:
B.	Other orders regarding tax exemptions (specify):
If a non-residential parent is entitled to claim the child(ren), the residential parent is required to
execute and deliver Internal Revenue Service Form 8332, or its successor, together with any other
required forms as set out in section 152 of the Internal Revenue Code, as amended, on or before
February 15th of the year following the tax year in question, to allow the non-residential parent to
claim the minor child(ren).
FIFTH: MODIFICATION
This Parenting Plan may be modified by agreement of the parties or by the Court.
SIXTH: OTHER
Upon approval by the Court, this Parenting Plan shall be incorporated in the Judgment Entry.
Signature (Plaintiff/Petitioner 1)	Signature (Defendant/Petitioner 2)
Date	Date