When faced with the complexities of domestic relations cases, particularly those involving financial matters such as child and spousal support, the Supreme Court of Ohio has laid out a clear path towards transparency and fairness through the adoption of the Uniform Domestic Relations Form – specifically, the Affidavit of Income and Expenses. Approved on May 25, 2010, and made effective from July 1, 2010, following an initial publication for comment in January 2010, these forms serve a crucial role in legal procedures by ensuring that all parties provide a complete financial disclosure. This comprehensive affidavit details income, expenses, debts, and the financial needs of children, if applicable, to facilitate informed decisions by the court. It prompts the reporting of various types of income, including base yearly income, overtime, bonuses, and benefits such as Social Security or unemployment compensation. Furthermore, it meticulously itemizes monthly housing and living expenses, alongside any child-related expenditures – painting a thorough financial picture of the household. Intended for use in the Court of Common Pleas across Ohio counties, these forms represent an essential tool in pursuing fair outcomes in domestic relations court proceedings.
| Question | Answer |
|---|---|
| Form Name | Uniform Domestic Relations Form |
| Form Length | 25 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min 15 sec |
| Other names | uniform domestic relations form 28, uniform domestic relations form 25, ohio uniform domestic relations forms, uniform domestic relations |
FORMS APPROVED BY THE SUPREME COURT OF OHIO
PURSUANT TO CIV. R. 84
The Supreme Court of Ohio, pursuant to Ohio Rule of Civil Procedure 84, approved on May 25, 2010 the following Uniform Domestic Relations Forms (Affidavits 1 through 5), which are effective July 1, 2010.
The history of these forms is as follows:
January 18, 2010 |
Initial publication for comment |
May 25, 2010 |
Final adoption by conference |
July 1, 2010 |
Effective date |
COURT OF COMMON PLEAS
COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
v./andMagistrate
Defendant/Petitioner
Instructions: Check local court rules to determine when this form must be filed.
This affidavit is used to make complete disclosure of income, expenses and money owed. It is used to determine child and spousal support amounts. Do not leave any category blank. Write “none” where appropriate. If you do not know exact figures for any item, give your best estimate, and put “EST.” If you need more space, add additional pages.
AFFIDAVIT OF INCOME AND EXPENSES
Affidavit of
(Print Your Name)
Date of marriage |
|
Date of separation |
SECTION I - INCOME
Employed
Employer
Payroll address
Payroll city, state, zip
Scheduled paychecks per year
Husband
Yes No
12 24 26 52
Wife
Yes No
12 24 26 52
A.YEARLY INCOME, OVERTIME, COMMISSIONS AND BONUSES FOR PAST THREE YEARS
Base yearly income
Yearly overtime, commissions and/or bonuses
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Husband |
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Wife |
$ |
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3 years ago |
20 |
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$ |
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$ |
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2 years ago |
20 |
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$ |
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$ |
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Last year |
20 |
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$ |
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$ |
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3 years ago |
20 |
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$ |
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$ |
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2 years ago |
20 |
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$ |
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$ |
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Last year |
20 |
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$ |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 1 of 7 |
B.COMPUTATION OF CURRENT INCOME
Husband
Wife
Base yearly income
Average yearly overtime, commissions and/or bonuses over last 3 years (from part A)
Unemployment compensation
Disability benefits
Workers’ Compensation
Social Security
Other:
Retirement benefits
Social Security
Other:
Spousal support received
Interest and dividend income (source)
Other income (type and source)
TOTAL YEARLY INCOME
Supplemental Security Income (SSI) or public assistance
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
$ |
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$ |
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$ |
$ |
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$ |
$ |
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$ |
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 2 of 7 |
SECTION II – CHILDREN AND HOUSEHOLD RESIDENTS
Minor and/or dependent child(ren) who are adopted or born of this marriage or relationship:
Name |
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Date of birth |
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Living with |
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In addition to the above children there is/are in your household: adult(s)
other minor and/or dependent child(ren).
SECTION III – EXPENSES
List monthly expenses below for your present household.
A.MONTHLY HOUSING EXPENSES
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Rent or first mortgage (including taxes and insurance) |
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$ |
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Real estate taxes (if not included above) |
$ |
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Real estate/homeowner’s insurance (if not included above) |
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$ |
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Second mortgage/equity line of credit |
$ |
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Utilities |
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O |
Electric |
$ |
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O Gas, fuel oil, propane |
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$ |
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O |
Water and sewer |
$ |
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O |
Telephone |
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$ |
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O |
Trash collection |
$ |
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O |
Cable/satellite television |
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$ |
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Cleaning, maintenance, repair |
$ |
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Lawn service, snow removal |
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$ |
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Other: |
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$ |
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$ |
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TOTAL MONTHLY : |
$ |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 3 of 7 |
B.OTHER MONTHLY LIVING EXPENSES
Food
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O Groceries (including food, paper, cleaning products, toiletries, other) |
$ |
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O |
Restaurant |
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$ |
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Transportation |
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O |
Vehicle loans, leases |
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$ |
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O Vehicle maintenance (oil, repair, license) |
$ |
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O |
Gasoline |
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$ |
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O |
Parking, public transportation |
$ |
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Clothing |
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O Clothes (other than children’s) |
$ |
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O |
Dry cleaning, laundry |
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$ |
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Personal grooming |
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O |
Hair, nail care |
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$ |
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O |
Other |
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$ |
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Cell phone |
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$ |
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Internet (if not included elsewhere) |
$ |
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Other |
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$ |
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TOTAL MONTHLY |
$ |
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C.MONTHLY
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$ |
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Other child care |
$ |
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Unusual parenting time travel |
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$ |
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Special and unusual needs of child(ren) (not included elsewhere) |
$ |
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Clothing |
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$ |
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School supplies |
$ |
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Child(ren)’s allowances |
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$ |
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Extracurricular activities, lessons |
$ |
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School lunches |
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$ |
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Other |
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$ |
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TOTAL MONTHLY |
$ |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
|
Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 4 of 7 |
D. |
INSURANCE PREMIUMS |
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Life |
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$ |
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Auto |
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$ |
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Health |
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$ |
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Disability |
$ |
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Renters/personal property (if not included in part A above) |
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$ |
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Other |
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$ |
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TOTAL MONTHLY |
$ |
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E. |
MONTHLY EDUCATION EXPENSES |
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Tuition
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O |
Self |
$ |
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O |
Child(ren) |
$ |
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Books, fees, other |
$ |
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College loan repayment |
$ |
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Other |
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$ |
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$ |
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TOTAL MONTHLY: |
$ |
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F.MONTHLY HEALTH CARE EXPENSES (not covered by insurance)
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Physicians |
$ |
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Dentists |
$ |
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Optometrists/opticians |
$ |
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Prescriptions |
$ |
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Other |
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$ |
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$ |
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TOTAL MONTHLY: |
$ |
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G. |
MISCELLANEOUS MONTHLY EXPENSES |
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Extraordinary obligations for other minor/handicapped child(ren) (not stepchildren) |
$ |
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Child support for children who were not born of this marriage or relationship and were |
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not adopted of this marriage |
$ |
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Spousal support paid to former spouse(s) |
$ |
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Subscriptions, books |
$ |
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Entertainment |
$ |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
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Page 5 of 7 |
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Charitable contributions |
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$ |
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Memberships (associations, clubs) |
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$ |
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Travel, vacations |
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$ |
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Pets |
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$ |
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Gifts |
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$ |
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Bankruptcy payments |
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$ |
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Attorney fees |
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$ |
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Required deductions from wages (excluding taxes, Social Security and Medicare) |
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(type) |
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$ |
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Additional taxes paid (not deducted from wages) (type) |
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$ |
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Other |
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$ |
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$ |
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TOTAL MONTHLY: |
$ |
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H. |
MONTHLY INSTALLMENT PAYMENTS |
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(Do not repeat expenses already listed.) |
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Examples: car, credit card, |
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To whom paid |
Purpose |
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Balance due |
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Monthly payment |
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TOTAL MONTHLY: |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
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Page 6 of 7 |
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GRAND TOTAL MONTHLY EXPENSES (Sum of A through H): $
OATH
[Do not sign until notary is present.]
I, (print name), swear or affirm that I have read
this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
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Your signature |
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Sworn before me and signed in my presence this |
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day of |
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, |
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Notary Public |
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My commission expires: |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 1 |
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Affidavit of Income and Expenses |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 7 of 7 |
COURT OF COMMON PLEAS
COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
v./andMagistrate
Respondent/Petitioner
Instructions: Check local court rules to determine when this form must be filed.
List ALL OF YOUR PROPERTY AND DEBTS, the property and debts of your spouse, and any joint property or debts. Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If more space is needed, add additional pages.
AFFIDAVIT OF PROPERTY
Affidavit of
(Print Your Name)
I. REAL ESTATE INTERESTS
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Address |
Present Fair Market |
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Value |
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1. |
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$ |
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Titled To |
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Mortgage |
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Equity |
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Balance |
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(as of date) |
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Husband |
$ |
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$ |
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Wife |
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Both |
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2.$
Husband |
$ |
$ |
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Wife |
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Both |
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TOTAL SECTION I: REAL ESTATE INTERESTS $
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 2 |
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Affidavit of Property |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 1 of 7 |
II. OTHER ASSETS
Category
A. Vehicles and Other Certificate of Title Property
1.
2.
3.
4.
5.
6.
Description
(list who has possession)
(Include model and year of automobiles, trucks, motorcycles, boats, motors, motor homes, etc.)
Titled To |
Value/Date of Value |
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
B. Financial Accounts
1.
2.
3.
4.
(Include checking, savings, CDs, POD accounts, money market accounts, etc.)
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 2 |
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Affidavit of Property |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 2 of 7 |
Category
C. Pensions
& Retirement plans
1.
2.
3.
4.
D. Publicly Held Stocks,
Bonds, Securities & Mutual
Funds
1.
2.
3.
4.
Category
E. Closely Held Stocks &
Other Business Interests and
Name of Company
1.
2.
Description
(List who has possession)
(Include
Description
(List who has possession) (Type of ownership and number)
Titled To
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Titled To
Husband
Wife
Both
Husband
Wife
Both
Value/Date of Value
$
$
$
$
$
$
$
$
Value/Date of Value
$
$
Supreme Court of Ohio
Uniform Domestic Relations Form – Affidavit 2 Affidavit of Property
Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010
Page 3 of 7
F. Life Insurance Type (Term/Whole Life)
1.
2.
3.
4.
Category
G.Furniture & Appliances
1.
2.
3.
4.
H. Safe Deposit Box
1.
2.
(Any cash value or loans)
Description
(Estimate value of those in your possession, and value of those in your spouse’s possession)
(Give location and describe contents)
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Who Has
Possession
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Husband
Wife
Both
Titled To
Husband
Wife
Both
Husband
Wife
Both
(Insured party
& value upon death)
$
$
$
$
Value/Date of Value
$
$
$
$
$
$
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 2 |
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Affidavit of Property |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 4 of 7 |
I. Transfer of Assets |
Explanation: List the name and address of any person (other than creditors listed on your |
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Affidavit) who has received money or property from you exceeding $300 in value in the past 12 |
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months and the reason for each transfer. |
1.
2.
3.
4.
Category
J. All Other Assets Not Listed Above
Description
(Also list who has possession)
Explanation: List any item you have not listed above that is considered an asset.
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Husband $
Wife
Both
Titled To |
Value/Date of Value |
1.
2.
Husband $
Wife
Both
Husband $
Wife
Both
TOTAL SECTION II: OTHER ASSETS $
III. SEPARATE PROPERTY CLAIMS:
If you are making any claims in any of the categories below, explain the nature and amount of your claim. This includes, but is not limited to, inheritances, property owned before marriage, and any
Category |
Description |
Why do you claim this |
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as a separate property? |
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etc., acquired after separation) |
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1.
2.
3.
4.
5.
Present Fair Market Value
$
$
$
$
$
TOTAL SECTION III: SEPARATE PROPERTY CLAIMS |
$ |
|
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 2 |
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Affidavit of Property |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
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Page 5 of 7 |
IV. DEBT
List ALL OF YOUR DEBTS, the debts of your spouse, and any joint debts. Do not leave any category blank. For each item, if none, put “NONE.” If you don’t know exact figures for any item, give your best estimate, and put “EST.” If more space is needed to explain, please attach an additional page with the explanation and identify which question you are answering.
Name of
Type Creditor/Purpose of
Debt
A. Secured Debt (Mortgages, Car, etc.)
1.
2.
3.
4.
5.
B.Unsecured Debt, including credit cards
1.
2.
3.
4.
5.
Supreme Court of Ohio
Uniform Domestic Relations Form – Affidavit 2 Affidavit of Property
Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010
Account Name |
Name(s) on |
Total Debt |
Monthly |
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Account |
Due |
Payment |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
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$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
$ |
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Husband |
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Wife |
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Joint |
$ |
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$ |
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TOTAL SECTION IV: DEBT |
$ |
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Page 6 of 7
V. BANKRUPTCY |
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Filed by: Wife, |
Date of Filing: |
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Date of Discharge |
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Type of Case |
Current Monthly |
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Husband, Both |
Case Number |
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or Relief from Stay |
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(Ch. 7, 11, 12, 13) |
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Payments |
1. |
Husband |
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Wife |
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Both |
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$ |
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2. |
Husband |
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Wife |
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Both |
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$ |
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TOTAL SECTION V: BANKRUPTCY |
$ |
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OATH
[Do Not Sign Until Notary is Present]
I, (print name)swear or affirm that I have read
this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
Your signature
Sworn before me and signed in my presence this |
|
day of |
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, |
|
. |
Notary Public
My Commission Expires:
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 2 |
|
Affidavit of Property |
|
Approved under Ohio Civil Rule 84 |
|
Effective Date: July 1, 2010 |
Page 7 of 7 |
COURT OF COMMON PLEAS
COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
v./andMagistrate
Defendant/Petitioner/Respondent
Instructions: Check local court rules to determine when this form must be filed.
By law, an affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court, including Dissolutions, Divorces and Domestic Violence Petitions. Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, add additional pages.
PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A))
Affidavit of
(Print Your Name)
Check and complete ALL THAT APPLY:
1.
2.
I request that the court not disclose my current address or that of the child(ren). My address is confidential pursuant to R.C. 3127.23(D) and should be placed under seal to protect the health, safety, or liberty of myself and/or the child(ren).
Minor child(ren) are subject to this case as follows:
Insert the information requested below for all minor or dependent children of this marriage. You must list the residences for all places where the children have lived for the last FIVE years.
a.Child’s Name:
Date of Birth:
Period of Residence |
Check if |
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Confidential |
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to |
present |
Address |
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Confidential? |
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Confidential? |
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Supreme Court of Ohio
Uniform Domestic Relations Form – Affidavit 3 Parenting Proceeding Affidavit
Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010
Place of Birth:
Sex: |
Male |
Female |
Person(s) With Whom Child Lived
(name & address)
Relationship
Page 1 of 4
b.Child’s Name:
Date of Birth:
Place of Birth:
Sex: |
Male |
Female
Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.
Period of Residence |
Check if |
Person(s) With Whom Child Lived |
|
Relationship |
||
Confidential |
(name & address) |
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to |
present |
Address |
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Confidential? |
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to |
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Confidential? |
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to |
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Confidential? |
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Confidential? |
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c. |
Child’s Name: |
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Place of Birth: |
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Date of Birth: |
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Sex: |
Male
Female
Check this box if the information requested below would be the same as in subsection 2a and skip to the next question.
Period of Residence |
Check if |
Person(s) With Whom Child Lived |
|
Relationship |
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Confidential |
(name & address) |
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to |
present |
Address |
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Confidential? |
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to |
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Confidential? |
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to |
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Confidential? |
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to |
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Confidential? |
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IF MORE SPACE IS NEEDED FOR ADDITIONAL CHILDREN, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .
3.Participation in custody case(s): (Check only one box.)
I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of, or visitation (parenting time), with any child subject to this case.
I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of, or visitation (parenting time), with any child subject to this case. For each case in which you participated, give the following information:
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 3 |
|
Parenting Proceeding Affidavit |
|
Approved under Ohio Civil Rule 84 |
|
Effective Date: July 1, 2010 |
Page 2 of 4 |
a.Name of each child:
b.Type of case:
c.Court and State:
d.Date and court order or judgment (if any):
IF MORE SPACE IS NEEDED FOR ADDITIONAL CUSTODY CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .
4.Information about other civil case(s) that could affect this case: (Check only one box.)
I HAVE NO INFORMATION about any other civil cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case.
I HAVE THE FOLLOWING INFORMATION concerning other civil cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning a child subject to this case. Do not repeat cases already listed in Paragraph 3. Explain:
a.Name of each child:
b.Type of case:
c.Court and State:
d.Date and court order or judgment (if any):
IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .
5.Information about criminal case(s):
List all of the criminal convictions, including guilty pleas, for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any domestic violence offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C.
2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense.
Name |
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Case Number |
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Court/State/County |
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Convicted of What |
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Crime? |
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IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX .
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 3 |
|
Parenting Proceeding Affidavit |
|
Approved under Ohio Civil Rule 84 |
|
Effective Date: July 1, 2010 |
Page 3 of 4 |
6.Persons not a party to this case who have physical custody or claim to have custody or visitation
rights to children subject to this case: (Check only one box.)
I DO NOT KNOW OF ANY PERSON(S) not a party to this case who has physical custody or claims to have custody or visitation rights with respect to any child subject to this case.
I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case.
a.Name/Address of Person Has physical custody Name of each child:
b.Name/Address of Person Has physical custody Name of each child:
c.Name/Address of Person Has physical custody Name of each child:
Claims custody rights |
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Claims visitation rights |
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Claims custody rights |
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Claims visitation rights |
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Claims custody rights |
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Claims visitation rights |
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OATH
[Do Not Sign Until Notary is Present]
I, (print name), swear or affirm that I have read
this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
Your signature
Sworn before me and signed in my presence this |
|
day of |
|
, |
|
. |
Notary Public
My Commission Expires:
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 3 |
|
Parenting Proceeding Affidavit |
|
Approved under Ohio Civil Rule 84 |
|
Effective Date: July 1, 2010 |
Page 4 of 4 |
COURT OF COMMON PLEAS
COUNTY, OHIO
Case No.
Plaintiff/Petitioner
Judge
v./andMagistrate
Defendant/Petitioner
Instructions: Check local court rules to determine when this form must be filed.
This affidavit is used to disclose health insurance coverage that is available for children. It is also used to determine child support. It must be filed if there are minor children of the relationship. If more space is needed, add additional pages.
HEALTH INSURANCE AFFIDAVIT
Affidavit of
Are your child(ren) currently enrolled in a
Are you enrolled in an individual (non- group or COBRA) health insurance plan?
Are you enrolled in a health insurance plan through a group (employer or other organization)?
If you are not enrolled, do you have health insurance available through a group (employer or other organization)?
Does the available insurance cover primary care services within 30 miles of the child(ren)’s home?
Supreme Court of Ohio
Uniform Domestic Relations Form – Affidavit 4 Health Insurance Affidavit
Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010
(Print Your Name)
Mother
Yes No
Yes No
Yes No
Yes No
Yes No
Father
Yes No
Yes No
Yes No
Yes No
Yes No
Page 1 of 2
|
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Mother |
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Father |
Under the available insurance, what |
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would be the annual premium for a |
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plan covering you and the child(ren) of |
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this relationship (not including a |
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spouse)? |
$ |
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$ |
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Under the available insurance, what |
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would be the annual premium for a |
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plan covering you alone (not including |
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children or spouse)? |
$ |
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$ |
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If you are enrolled in a health |
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insurance plan through a group |
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(employer or other organization) or |
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individual insurance plan, which of the |
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following people is/are covered: |
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Yourself? |
Yes |
No |
Yes |
Your spouse? |
Yes |
No |
Yes |
Minor child(ren) of this |
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relationship? |
Yes |
No |
Yes |
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Number |
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Number |
Other individuals? |
Yes |
No |
Yes |
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Number |
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Number |
Name of group (employer or organization) that provides health insurance
Address
Phone number
OATH
[Do not sign until notary is present.]
No No
No
No
I, (print name), swear or affirm that I have read
this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
|
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Your signature |
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Sworn before me and signed in my presence this |
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day of |
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, |
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. |
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Notary Public |
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My commission expires: |
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Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 4 |
|
Health Insurance Affidavit |
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Approved under Ohio Civil Rule 84 |
|
Effective Date: July 1, 2010 |
Page 2 of 2 |
COURT OF COMMON PLEAS
COUNTY, OHIO
Case No.
Plaintiff
Judge
v.Magistrate
Defendant
Instructions: Check local court rules to determine when this form must be filed.
This form is used to request temporary orders in your divorce or legal separation case. After a party serves a Motion and Affidavit, the other party has 14 days to file a Counter Affidavit and serve it on the party who filed the motion. If more space is
needed, add additional pages.
MOTION AND AFFIDAVIT OR COUNTER AFFIDAVIT
FOR TEMPORARY ORDERS
WITHOUT ORAL HEARING
Check one box below to show whether you are filing a (1) Motion and Affidavit or (2) Counter Affidavit.
(1) Motion and Affidavit
(Print Your Name) |
|
files this Motion and Affidavit |
under Rule 75(N) of the Ohio Rules of Civil Procedure to request the temporary orders checked here.
Check only those that apply. |
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Residential parenting rights (custody) |
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Parenting time (visitation) |
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Child support |
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Spousal support (alimony) |
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Payment of debts and/or expenses |
THE OTHER PARTY HAS 14 DAYS FROM THE DATE ON WHICH THIS MOTION IS SERVED TO FILE A COUNTER AFFIDAVIT AND SERVE IT UPON THE PARTY WHO FILED THE MOTION. (See below.)
(2) Counter Affidavit |
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(Print Your Name) |
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files this Counter Affidavit in |
response to a Motion and Affidavit. |
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Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 5 |
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Motion and Affidavit or Counter Affidavit for Temporary Orders |
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Without Oral Hearing |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 1 of 4 |
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Complete the following information, whether filing Motion and Affidavit or Counter Affidavit. Check all that apply.
1.
My spouse and I are living separately. |
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Date of separation is |
. |
My spouse and I are living together. |
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We have no minor children. (Skip to number 5.) |
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There are minor child(ren) who are adopted or born of this marriage. |
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(List children here.) |
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Name |
Date of birth |
Living with |
In addition to the above children there is/are in my household: adult(s)
other minor and/or dependent child(ren).
2.My child(ren) attend(s) school in:
Father’s school district
Mother’s school district
Open enrollment
Other (Explain.). All children do not attend school in the same district. (Explain.)
3.
I request to be named the temporary residential parent and legal custodian of the child(ren). (Specify child(ren) if request is not for all children.)
I do not object to my spouse being named the temporary residential parent of the child(ren). I request the following parenting time order:
The Court’s standard parenting order (See county’s local rules of court.)
A specific parenting time order as follows:
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 5 |
|
Motion and Affidavit or Counter Affidavit for Temporary Orders |
|
Without Oral Hearing |
|
Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 2 of 4 |
I have reached an agreement regarding parenting time with my spouse as follows:
I request that my spouse’s parenting time (visitation) be supervised.
Name of an appropriate supervisor
4. A court or agency has made a child support order concerning the child(ren). Name of Court/Agency
Date of Order
SETS No.
5.I request the Court to order my spouse to pay:
$ |
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child support per month |
$ |
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spousal support per month |
$ |
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attorney fees, expert fees, court costs |
The following debts and/or expenses:
6.
Other
I am willing to attend mediation.
I am not willing to attend mediation.
I request the following court services. (See local rules of court for available services.)
State specific reasons why court services are required.
Supreme Court of Ohio |
|
Uniform Domestic Relations Form – Affidavit 5 |
|
Motion and Affidavit or Counter Affidavit for Temporary Orders |
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Without Oral Hearing |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 3 of 4 |
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OATH |
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[Do not sign until notary is present.] |
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I, (print name) |
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, swear or affirm that I have read |
this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury.
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Your signature |
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Sworn before me and signed in my presence this |
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day of |
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, |
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. |
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Notary Public |
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My commission expires: |
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NOTICE OF HEARING
(Check with local court for scheduling procedure.)
You are hereby given notice that this motion for temporary orders will be heard upon affidavits only, and |
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without oral testimony, before Judge/Magistrate |
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Hearing Room |
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a.m./p.m. on |
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floor . |
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CERTIFICATE OF SERVICE |
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Check the boxes that apply. |
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I delivered a copy of my: |
Motion and Affidavit or |
Counter Affidavit |
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On: |
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(Date) |
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, 20 |
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To: |
(Print name of other party’s attorney or, if there is no attorney, print name of the party.) |
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At: |
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(Print address or fax number.) |
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By: |
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U.S. Mail |
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Fax |
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Messenger |
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Clerk of courts (if address is unknown) |
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Your signature |
Supreme Court of Ohio |
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Uniform Domestic Relations Form – Affidavit 5 |
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Motion and Affidavit or Counter Affidavit for Temporary Orders |
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Without Oral Hearing |
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Approved under Ohio Civil Rule 84 |
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Effective Date: July 1, 2010 |
Page 4 of 4 |