affidavit of income expenses and financial disclosure
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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. '
COURT OF COl\Ii\ION PLEAS
DIVISION OF DOMI':STIC RELATIONS
HAMn,TON COUNTY, OHIO
MELISSA HENDON DETERS
Plaintiff
Date:
Case i'/o.
File No.
CSEA No.
Judge
DR1302
2
34
Address: 11976 Stonernark Lane
Loveland, 011
45140
VS.
AFFlDAVIT OF Ii'/COME, EXPENSES
A, D FINA.l'\'CIAL IJISCLOSURE
JOSEPH THEODORE DETERS
Defendant
Address: 15 W Fourth Street #503
Cincinnati, OH 45202
STATE OF OH IO , SS :
N ow comes M elis 'a H end on D eters, affi an t h er ei n, and having been duly cautio ned and swor n, st ate s that she has
been adv ise d th at this affida vit may be used for any or all of the fo llow ing purposes: (I) to m ake complete d isclo sure of
a ff ia nt 's i ncome, liabilities an d expenses; (2) t o a ss ist in dete rmining ord ers o f ch ild sup port o r spo usa l su pp ort w hen
a pp li ca ble o r any ch ange s th eret o; and
(3)
to provi de for the issuance of the ap pro priate de duction ord er for s up po rt.
M inor and/or Depende n t Children of thi s Marriage:
~P- .a- -tn.:..:: c: :.:k ,-,,J,,-. D e te ,rs ,-, ag e 9 i s r e sid ing w ith . . : . . . 1 _
... ,tv -'ra - 'ry~E I~yse '_ 'D =et e_ '_ 'rs '__ age 20 i s r e sid ing w ith ..:...1 _
= .:Jo~nC a .th .. a~n_'_' . . . . .r '_'.~et e_'_ 'rs '__ age
23
is re siding w ith _
,Jo ,:; c p-,-,-h-,,S,,-. D :..>e -'te -'.f--s age
::.24-'--
i s r e sid ing w ith _
GROSS YEARLY INCOME
SECTrON r
Husband
$87.828.00
(1)1
Yes_ No Em ployed?
l
Ycs_ No
(2)
Wife
... ....... Estimate Base yearly wages Estimare $50.000.00
........ .... ....... ...... Y e arly A ve ra ge s, O v ert im e, C o mm is sio n
&
Bonu s Incom e
$ O - ' . - . O O ~ _
0.00
H am ilto n C ou nty Prosecu to r
Employe r
Public Librnry of Cincinnati and
Ham il to n C ou nt y F ou nd at io n
80 0 V ine S treet
3Q
E . 9 th S treet S uite
Pa yr oll A dd ress
City, Stat e, Z ip
S chedu led Pay checks Per Y ear
Unemploy ment Benefits
Workers' Compensation
S o ci al S ec ur ity or O ther D is ab il it y B e ne fi ts
L is t S o ur ce in S ection D -2
Spousa l Support Received
Interest/D ividend Incom e
L is t S o ur ce in Sectio n
0-2
Public A ssistance or
I nc om e S u pp le m ent Security
O th er In co me Rece ived
list
Source in S ection IIl-B
TOTAL YEARLY INCOME
Cinc innati. Oh io 45202
.... ... ........ ...... ... . 1 2 .
$0.00
$0.00
$0.00
$0.00
0 00
S O . O O
$202,800 $0.00
$290.628.00
$50.000.00
D R 7.3 (Revised 07 /01 /2001)
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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Husband (I) Wife (2)
ANNUAL INCOME, OVERTIME AND BONUSES EARI~ED
(Past Three Years)
Overtime.
and/or
Bonuses
2 0 1 0
year
3 . .. '- $ 0 - ' . ' 0 0 - - - -_ $ 0 - ' - . 0 - '0 - -_
2 0
I
I year
2 .
$ 0 . 0 0 -- - - _ _ $ 0 '- . 0 ' 0 - -_
2 0 1 2 year I . . . = $ 0 = . 0 ' 0 ' -- - _ _ $ 0 .0 0
Base Income Base Income
Overtime,
and/or
Bonuses
$ 0 . 0 0
0 1 0
year
3 = $ O ~ .O = O _
2 0 I I
year
2
= S O - , . , ,o O ~ _ _
2 0 1 2
year I
$ 0 = . 0 '0 ' - - - _ _
$ 0 . 0 0
S O .O O per year
S O per year
MOST RECENT
YEAR
D.JUST;\,I ENTS
.............. Court Ordered Support Paid for other child(ren) .
........ Court ordered Spousal Support Paid to a Fonner Spouse .
. .. .. Number of Other Dependant Children living with the Party .
(Excluding Unadopted Step Children)
.... .. .. . Child Support Received for Other Dependent Children
$
--'p e::..r..r.V 'C . , 3 = 8 = 3 ~ . 8 ; . . : . . 1 _
DR
7 . 3
(Revised
0 7 1 0 1 1 2 0 0 1 )
PI .2
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C. MONTHLY INSTALLMENT PAYMENTS
(Do not list expenses previously listed in Section B)
TO WHOM PAID PURPOSE BALANCE DUE
MONTHLY
PAYMENT
$500.00
ifth Third Master Card
Credit Card
11,403.79
Fifth Third Master Card Credit Card
7,855.36
$500.00
Visa
Credit Card
14,195.19
$500.00
AAA- Bank of America
Credit Card
9.500.00
S500.00
Bank of America Visa Credit Card 34,000.00 $1,000.00
Macy's American Express
Credit Card
$125.00
GE
Credit Union
Buick Loan 41 \3 .0 0
VWCredit
Passat Loan
$155.37
MONTHLY TOTAL
$3,763.37
$18,486.75
GRANO TOTAL MONTHLY EXPENSES (Sum A, B, C, plus D (optional) .
SECTION III FINANCIAL DISCLOSURE
A. list all funds on deposit in any and all accounts in any bank, savings loan, credit union, regulated investment
company, mutual fund or other financial institution. Account includes any of the following: checking, certificate of
deposit ( CD), investment, savings, individual retirement ( IRA), stock option, etc. Attach additional pages
if
needed.
Name and Address of
Financial Institution
Fifth Third Bank
Account No. Name(s) on Accounts Balance Dat e of
this Affidavit
xxx586 Joseph Deters
S ;
Filth Third Bank
x x x 5
Joseph and Melissa
$
Deters
Huntington Bank
x x x 4
Joseph and M elissa
Deters
Huntington Bank
xxx06n
Melissa Deters
Fifth Third Bank
Melissa Deters $
Huntington Bank xxx760 Melissa Deters
B.
Other income sources listed in Section
I (i.c.,
retirement/pension benefits, disability income, interests or dividend
income, rentals, annuities, etc., not listed in Section III-A). Attach additional pages if needed. Need not complete prc-
decree.
Name & Address of Source
Identifying Description
(Account No., Claim No., etc.)
Income
or Benefits
Per Month
$ per _
O
DR 7.3 (Revised 0710112001)
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;;
SECTION IV
OTHER ASSETS AND LUMP SUM TNCOME
1. Describe assets of more than $1,000 in value not otherwise listed in this affidavit (equity in real estate, stocks,
b on ds , o th er in ve stm e nt s, e tc .) , A tt ac h a d di ti on a l p a ge s
if
needed .
NONE
Value
_
2 . L ist any lum p sum incom e (bonus, g ifts , inhe ritance, e tc .) in excess
of
$5 00 , expected to be received w ith in the next
si x months, not otherwise listed in this affidavit. Attach additional pages if needed.
Source NONE
Value '$ _
A ddrcss _
Affiant states that the information contained herein is complete and accurate to the best of his/her information,
kn ow led ge or b elie f un der p en alty of
law.
Atfi
n t:
tto rn ey f or P la in tif f
______ ,2o~3
i A M g d H , M O ~ K O W n t .
A t t 5 I 'i l 8 i
d U J 1 1 I
aTARY
PUBliC. 'TATS 0 1' o J ff O
My Cornrnlsalon has no explrctUOlT
dote. 64 CUoo
147.03
OACt
D R 7 J ( Re vis ed 0 7/0 1 (2 0 01 )
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I
D. OPTIONAL
(Additional Monthly Expenses)
Complete if an award of spousal support is at issue or in the event that you are seeking a significant deviation from the
child support schedule.
I .
Special and Unusual Needs of the Children, Specify: ,,
$ 0 . 0 0 _
2 .
Extraordinary Visitation-Related Travel Expenses
, $ 0 ' . 0 ' - 0 _
3. Extraordinary Obligations to other children, minor and handicapped, not step-children
. $ 0 . 0 0 ' -- _
4 . Mandatory Deduction from Wages (Not taxes, Social Security . O ~ . O O ' -- _
5 .
Hair Care, Dry Cleaning
.$ 2 :: . . . 4 . - 2 - - ' . 5 ' - - ' : 0 ~ _
6. Newspapers, Periodicals, and Books
$ 0 . 0 0 ' - _
7 .
Child Care (not
e m p l o y m e n t
related) , ..
' $ - 0 ' - . 0 .. . , 0 ' - - _
8 . Children'S School Lunch Program . $ . . : . . . 1 0 . 0 0 - _
9. Children's Allowances, Activities . , , $ - ' - - 7 0 - - ' 0 ' - . 0 0 - - _
1 0 .
Tuition (lor Minor Children or Sell)
' S 1 . L . . 4 '6 6 ' . : < , 0 ' 0 _
I I .
Entertainment
. $ ' - 4 - ' - ' 5 : < . 0 ' - ' - . 0 ' - ' 0 ~ _
1 2 . Contributions $ . . . , 1 0 .. . ,0 ' - . 0 0 ' -- _
1 3.
Additional Taxes Paid (not from wages $ 0 ' . : . = , 0 0 _
14. Memberships (Associations, Clubs)
. $ - :< . 7 8 ~ . - - 0 0 - - _
1 5 . Travel, Vacations
. $ = 2 = 0 - ' 0 ' - ' - . 0 0 - - _
16. Water Softener $ 0 . 0 0 ' - - _
1 7 .
Housing Repairs
$ . . . . , 1 0 . . , 0 '. 0 0 - - _
1 8 . Housekeeping
S e r v i c e s
'$ . : . . ; 1 0 0 '. 0 0 ' - - _
1 9. L aw n Service .$ ' - ' - ' I R . : . . , : 4 . 0 '0 ' - - _
2 0 . O t h e r ( S p e c i f y ) S ch o o l s u p p l i e s % - , $ - ' - ' 1 5 . 0 = - 0 - - _
Gift, .$ 2 ' 5 ' 0 . 0 - -- 0 _
Sorority '- $ 4 . - ' ' ' ' ' 6 '' ' '' . 0 ' ' ' ' '0 ' ' - - _
Pets
$ 2 5 . 0 0
Mary Elyse Deter Rent $ 6 8 5 . 0 0
Cable for Boys $ - ' - - 8 . . , 0 . 0 ' 0 ' - - _
TOTAL OTHER EXPENSES
(D)
$ 5 . 2 0 1 . 5 0
D R 7.3 (R ev ise d 0 7 / 0 1 1 2 0 0 I)
1 \ . 5
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I
~.,
COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
MELISSA HENDON DETERS
Date: _
Plaintiff
Cas e No.
D R 1 3
a
2
2 3 4
vs.
File No. _
JOSEPH THlWDORE DETERS
Defendant
CSEA No. _
Judge _
AFFIDAVIT
fN COMPLIANCE
WITH
Q 2723 OF THE mllo REVISED CODE
Melissa Hendon Deters discloses the following information under oath and represents that it is true to the best
of Wife knowledge and belief based upon what is reasonably ascertainable:
I.[
1 [
am requesting the court to not disclose my address or that of the child named below. Iam claiming t i H 1 I
my address is co nf ident ial pursuant [QOhio Revised Code 3127 .23(D) and should be placed under seal in that the health,
safety, or liberty of myself and/or the child would be jeopardized by the disclosure of the identifying inform ation. I
understand that a hearing will be held to determine whether the information can be disclosed based on
my
claim.
2 .
The name(s) and the present addressees), or the whereabouts,
oft he
child involved lire:
01. Patrick J. Deters
DOB 5/8/04
Present address:
1 1 976
Stonemark
Lane Loveland. Ohio 45140
3. The child have lived at the following addresstes) during th e las t 5 years:
Prior Address( es)
8256
Cherry laurel Court Liberty Township. Ohio45044
4. The name(s) and present address/es) of all persons with whom the child have lived during the past 5 years are:
J
oseoh Deters
Names
Melissa Deters and Marv Elyse Deters
Address] es)
11976 Stonemark Lane Loveland, Ohio 45140
1 5 W. FourthStreet #503, Cincinnati, Ohio 452Q2
37 37
Hazel Avenue Cins;innati, Ohio
4 5 2 1 2
onathan T. Deters and Joseph S. Deters
~ c:;. 5. I have not participated as a party, a witness, or in any way in so m e court action in this or another state
~ ~ ~ cercemint:i custody, support, care of or visitation or parenting time with these same child.
1j3~ < 1 . lWve
part ic ipa ted , I
have listed below the court, the case number, and kind of case:
o ?
7 .
u
') ('oJ \
~u-\...'
N ~
0 .
Case Num~ Name of Court Kind orCase
0~ ~
U --
d. e x . ..:N o. :~~ _
~\.J'J ~
DR 2.1 (May 2006)
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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DIVISION OF DOMESTIC RELATIONS
COURT OF COlVUvlON PLEAS
HAMILTON COUNTY, OHIO 0 R 1 3 0 2 '2 3 4
I\lcll~'Il1 Hendon Deters
Plalntitf
Case No. _
File
No. _
CSE,'
1 '. ' 0 . _
.JlId~e _
Jo se ph T heedore D eters
Defendllnt
GHOUP IIE,\LTH INSlmANCE ,'FrIOA IT
. ~ * ..
* .
* ....
. ;fr **
PL\l1\TIFF
DEFE:DANT
_y
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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DR624
EFF.10/08
Hamilton COUNTY DOMESTIC RELATIONS COURT
CHILD SUPPORT COMPUTATION WORKSHEET
SOLE RESIDENTIAL PARENT OR SHARED PARENTING ORDER
Name of parties
Husband
and
Wife
Case No.
Order No.
Number of minor children
1
The following parent was designated as residential parent and legal custodian:
t 8 J
mother
father
shared
Column I
Column II Column III
Father
Mother
Combined
INCOME:
1. a.
Annual gross income from employment or, when determined
appropriate by the court or agency, average annual gross
income from employment over a reasonable period of years
(Exclude overtime, bonuses, sel f-employment income,
or commissions) .......................................
281,220
49.992
b. Amount of overt ime, bonuses, and commissions
(year 1 represent ing the most recent year)
Father Mother
Yr. 3
(Three years ago) . . . .
Yr. 2
(Two years ago) ......
Yr. 1 (Last calendar year) ...
AVERAGE .............
(Include in Col. I and/or Col. /I the average of the three years or
the year 1 amount, whichever is less, if there exists a reasonable
expectation that the lotal earnings from overtime and/or bonuses
during the current calendar year will meet or exceed the amount
that is the lower of the average of the three years or the year 1
amount. If. however, there exists a reasonable expectation that
the total earnings from overtime/bonuses during the current
calendar year will be less than the lower of the average of the 3
years or the year 1emount, include only the amount reasonably
expected to be earned this year.) ..........................
0
0
2.
For self-employment income:
a. Gross receipts from business ..............................
0
s
0
b. Ordinary and necessary busmess expenses ...................
0
0
c. 5.6% of adjusted gross income or the actual marginal difference
between the actual rate paid by the self-employed individual
and the F.I.C.A. rate ....................................
s
0
0
d. Adjusted gross income from self-employment
(Subtract the sum of 2b and 2c from 2a) ......................
0
0
3.
Annual income from interest and dividends
(whether or not taxable) .................... _ .............
0
0
4. Annual income from unemployment compensation ..............
$
0
s
0
O l62 4 E ffe ct ; , 1 0 1 (1 8
MoskowItz Moskcwtz, t LC Prep ared b y J ames H. MoskowItz. Eq. James Mosko wi tz (e) Fa mi ly L aw Software. Inc . v 15.03 11120t2QIJ ,:03pm HUSband' & Wile
Pogo 1
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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Case No.
Order No.
Column I
Father
Column II
Mother
Column III
Combined
5. Annual income from workers' compensation, disability insurance
benefits, or Social Security Disabil ity/Retirement benefits ._~ __
. . : . O
. . : . 0
6. Other annual income (identify) , . , $
. . . . : : . 0
__ ..:..:1
: . . : 0 : . . c , D : . . : D : . . : : . D
Mother:
Alimony from this relationship , 1 8 0 , 0 0 0
7. a. Total annual gross income (Add lines 18, 1b, 2d, and 3-6)
b. Health insurance maximum (Multiply line 78 by 5%), , , ,
2 8 1 , 2 2 0 $ _ - - -- = 2 .: : . . 2 9 : . , : , 9 :. . : 9 :. . . : : c 2
1 4 , 0 6 1 1 : . . . : 1 2 . : .5 : . : : . . : : .
ADJUSTMENTS TO INCOME:
B.
Adjustment for minor children bom to or adopted by either
parent and another parent who are living wi th this parent;
adjustment does not apply to stepchildren (number of
children limes federal income tax exempt ion less child
support received, not to exceed the federal tax exempt ion) ,$ . . . . : : . 0
. . : . 0
9.
Annual court-ordered support paid for other children , , , , , .. ,
,,$
: 0
: 0
10, Annual cour t-ordered spousal support paid to any spouse or
former spouse. , . , , , . .. , . , .... , , , , . , , , , . , . , .. , , . , , , ...
1 8 0 , 0 0 0 - - = . O
11.
Amount of local income taxes actually paid or estimated to
be paid , , , , , , , .. , , , . , . . ..
5 , 9 0 6
1 ' : : 0 : . . : 5 : . . : : . 0
12.
Mandatory work-related deductions such as union dues,
uniform fees, etc. (not including taxes, Social Secun ty, or
retirement) ..... , , . , . , ... , , , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : . 0 . . : : . 0
13.
Total gross income adjustments (Add lines 8 through 12) . . . . . . . ..
1 8 5 , 9 0 6 __ . . . : 1 c . .: , O : . : 5 ~ 0
14. a. Adjusted annual gross income
(Subtract l ine
13
from line 7a)
__
.. . : 9 : . : 5 c . . : , 3 : . : 1~4
b. Cash medical suppor t maxJmum (If the amount on line 7a, Col. I,
is
under 150 of the federal poverty level for an individual,
enter SO on l ine 14b, Col. I. If the amount on line 7a, Col. I,
is 150 or higher
of
the federal poverty level for an individual ,
multiply the amount on line 14a. Col. I, by 5% and enter this
amount on line 14b, Col.
I.
If the amount on line 7a, Col. II,
is under 150 of the federal poverty level for an individual,
enter S O on line 14b, Col. II. If the amount on line 7a, Col. If,
is 150 or higher of the federal pover ty level for an individual,
multiply the amount on /ine 14a, Col. II, by
5%
and enter this
amount on line 14b. Col. If.) , .. .~ __ 4 : : . , 7 : . . : 6 : . . : : 6
2 2 8 , 9 4 2
1 1 , 4 4 7
15.
Combined annual income that is basis for child support order
(Add line 14a, Col, I and CoI , / I ) , , , , , . . . . . . . . . . . . . . . , , ,
$__
3 _ 2 4 . . : . . , 2 _ 5 _ 6
0 .6 2 4 E ffe c Uv e 1 0 1 0 8
r . 10SkOWi t z
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by J am es H ,
Moskowitz.
Esq. J ame s
Moskowitz
(c ) Fam i l y
LU' t 'VSoftware.
In c . v
15.03 1 1 12OO01 J
1 : pm HUSba n d
Wile
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. '
Case No.
Order No.
Column I
Father
Column II
Mother
Column III
Combined
16. Percentage of parent's income to total income
a. Father
(Divide line 14a. Col.
I.
byline
15.
Col. I II). . . . .. . . .. .
29.39 %
b.
Mother (Divide line 14a. Col.
1/.
by line
15,
Col. 1 1 / ) . . .. . . .. . . . . . . . .. . . . .. . .. . .
70.61 %
1 7 .
a.
Basic combined child support obligation (Refer to schedule, first
column. locate the amount nearest to the amount on line 15.
Col.
I I I .
then refer to column for number of children
in
this
family. If the income of the parents is more than one sum but
less than another. you may cetcutete the difference.) _~_1_5,-,,-,2_1_8
b .
Income above top guideline bracket.
1 7
4.256
C. Percenttobeusooonincomeover 150.000......... 10.1453
%
d.
Support on Income over 150.000 (b c 1 _ 7 . : . . , 6 _ 7 _ 9
o. Total child support obligat ion (a + d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
$~ __
3_2..:..,8_9_7
18. Annual support obligation per parent
a. Father (Multiply line 17c, Col. 1 1 by line 16a) 9,668
b. Mother (Mult iply l ine 17c, Col. I I I , by line 16b) $~ __ 2 - , 3 - , - . 2 _ 2 _ 9
19. Annual child care expenses for children who are the subject
of this order that are work-, employment training-. or
education-related. as approved by the court or agency _~~ __
O
0
(Deduct tax credit from annual cost, whether o r not claimed)
a. Less: Federal chi ld care tax credit .......................... 0 0_
b. Less: OH child care tax credit ........................... 0 0
c. Net child care costs 0 0
20. a. Marginal, out-of-pocket costs. necessary to provide for health
insurance for the children who are the subject of this order
(Contributing cost of private family health insuranco,
minus the contributing cost of private single neet tn
insurance. divided by /he total number of dependents
covered by the plan. including the children subject of the
support order, t imes the number
01
children subject of the
support order)
0
- ' - 0
b. Cash medical support obl igation (Enter the amount on line 14b or
the amount of annual health care expenditures est imated by
United States Department of Agricul ture and described in section
3119.30 of the Revised Code. whichever amount
is
lower). . . . . . ..
1 . 2 8 9 1 . : . . : . . 2 . . . ; . . 8 . . ; . . 9
21. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED:
Father (only
if
obligor or shared parenting) Mother (only i f obligor or shared parenting)
a. Additions; line 16a times sum of amounts shown on b. Additions: line l6b times sum of amounts shown on
line 19c. Col. I/and line 20a, Col. /I tine 19c. Col. I and line 208, Col. I
$ 0 _
C. Subtractions; line lob times sum of amounts shown on d, Subtractions: line 16a times sum of amounts shown on
line 19c, Col. I and line 20a, Col. I line 19c. Col. /I and line 20a, Col. /I
0
_
v,
D L6 24 E H~ tt l , \ 0 1 08
MoskOWitz
&
Mos;owito:. tlC Prep.:lIrod byJ
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8/10/2019 Affidavit of Income Expenses and Financial Disclosure
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.
Case No.
Order No.
Column I
Father
Column 1 1
Mother
22. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED:
a. Father: line 18a plus or minus the dif ference between line
21a minus line 21,c 9,668
b.
Mother.
line 18b plus or minus the difference between line
21b minus line 21d 23.229
23.
ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS PROVIDED:
a. (Line 22a or 22b, whichever line corresponds to the
parent who is the obligor) __ - - = 9 J . ; , 6 : . ; 6 : . : : . 8
b. Any non-means-tested benefits. including Social Security
and Veterans benefits. paid
1 0
and received by
a
child
or a
person on behalf of the child due to death. disability. or
ret irement of the parent . ; ; . . 0
c. Actual annual obligation (Subtract line 23b from line 238). . . . . . . .. $__ - - = 9 ~ , 6 : . : 6 : . : : . 8
_---
_---
_---
24. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED:
Father (only i f obligor or shared parenting) Mother (only if obligor or shared parenting)
a. Additions:
line 16a times sum of amounts shown on b.
Additions:
line
lob
times
sum of amounts shown on
line 19c. Col. I f and line 20b. Col. If line 19c, Col.Ind line 20b, Co/. I
$ 379
_
c. Subtractions: line t6b times sum of amounts shown on d. Subtractions: fine 16a times sum of amounts shown on
line 19c, Col. J and line 20b, Col. I line 19c. Col. 1/and line 2Gb. Cof. /I
$ 910
. ~
25. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED:
a. Father: line 18a plus or minus the dif ference between line
24a
minus l ine 24c
9,137
b. Mother.
fine 18b plus or minus the difference between line
24b and fine 24d . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ..
23,229
26.
ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS NOT PROVIDED:
a.
(Line 25a or 25b, whichever line corresponds to the parent
who is the obligor) ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9,137 _
b.
Any non-means-tested benefits, including Social Security
and Veterans benefits, paid to and received by a child or a
person on behalf of the child due to death, disability, or
retirement of the parent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 $. _
c. Actual annual obligation (Subtract line 26b from line 26a) . . . . . . . .. 9,137 _
27. a. Deviat ion from sole residential parent suppor t amount shown on line 23c if amount would be unjust or inappropr iate:
(see section 3119.;?3 of the Revised Code.) (Specific facts and monetary value must be stated. )
i. Sole custody deviation when heal th insurance is provided 40 000 _
ii. Sole custody deviation when health insurance NOT is provided 0 _
D l6 2 4 E ff ec ti ve 1 0 1 M
Moskowltz MoskOWitz. l Prepared by James H. MoskOWItz..ESQ.James Moskowitz c) Family Law
Software,
Inc. v 15.03 11120120131:03pm Husband & .
Wife
-
8/10/2019 Affidavit of Income Expenses and Financial Disclosure
13/13
Case No.
Order No.
b. Deviation from shared parenting order. (see sections 3119.23 and 3119.24 of the Revised Code.) (Specific facts including
amount of time children spend with each parent, ability of each parent
/0
maintain adequate housing for children, and
each parents expenses for children must be stated 10 juslify deviation.)
i. Shared custody deviation when health insurance is provided:
ii. Shared custody deviation when health insurance is NOT provided:
WHEN HEALTH
INSURANCE IS
PROVIDED
WHEN HEALTH
INSURANCE IS
NOT PROVIDED
OBLIGOR
Father/Mother
28. FINAL CHILD SUPPORT FIGURE:
(This amount reflects final annual child support obligation;
in Col. I, enter line 23c plus or minus any amounts indicated
in line 27a or 27b; in Col. II. enter l ine 26c plus or minus any,
amounts indicated in line 2 7a or 27b) . . . . . . . . . . . . . . . . . . . . . .. $
49,668 $
---- --
, 1 3 7
FATHER
29. FOR DECREE: Child support per month (Divide obligors In 28., by 12)
... before any processing charge . . . . . . . . . . . . . . . . . . . . . . . . .. 4 ,1 39
-.: 7... .::6'-'.1
. . . 2 %
processing charge of ; ..
8 _ 3
1 .. :. . 5
... including processing charge 4 .2 2 2 .. : . . 7 . . . : . 7 . c : , 6
30. FINAL CASH MEDICAL SUPPORT FIGURE:
(This amount reflects the final. annual cash medical support
to be paid by the obligor when neither parent provides health
insurance coverage for the child; enter obligors cash
medical support amount from fine 20b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 1 ,289
31. FOR DECREE: Cash medical support per month (Divide In 30. by 12)
... before any processing charge 1 07
.. . 2 % processing charge of
2
... including processing charge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 109
Prepared by:
Counsel:
Pro se:
(For motherlfather)
CSEA:
Other. _
Worksheet Has Been Reviewed and Agreed To:
Mother
Date
Father
Date
0 .6 24
E H e c U . . . ,
10 1 08
Moskowitz
Mo,kow;'z, LLC PrOP od by James H. Moskowllz, Esq. James Moskowitz (e) Family Law Softwa
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