COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)IN THE COURT OF COMMON PLEAS OF ASHLAND COUNTY, OHIO DOMESTIC RELATIONS DIVISION,Case No. Plaintiff/Petitioner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vs/and,HEALTH INSURANCE ORDER Defendant/PetitionerTHE PEOPLE OF THE STATE OF NEW YORK TOO.R.C. 3119.30 et seq. (Rev. 9-13-03)The following group health insurance and health care policies, contracts, and plans are available at a reasonable cost to the obligor or obligee: Name of Plan/InsurerAvailable to:Policy/Contract #GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,(Complete one of the following four (4) alternative ORDERS -Delete any not required)located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomALTERNATIVE 1: ORDER ON OBLIGOR -R.C. 3119.30(A)The Court finds that the Obligor under the child support order is and that the Obligor should be ordered to obtain group health insurance coverage through:Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Name of Employer or Group Plan and that health insurance coverage is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to the Obligee., one of the Justices of theCourt in Witness, Honorableday of, 20 County,IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that no later than 30 days after the issuance of this order, the Obligor shall obtain health insurance coverage for the following child(ren):(Attorney must sign above and type name below)NameS. S. NumberDate of BirthAttorney(s) forOffice and P.O. Addressand furnish written proof to the Ashland County Child Support Enforcement Agency that the required health insurance coverage has been obtained.Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)ALTERNATIVE 2: ORDER ON OBLIGEE -R.C. 3119.30(B)The Court finds that the Obligee under the child support order is and that the Obligee should be ordered to obtain group health insurance coverage through:Name of Employer or Group Plan and that health insurance coverage is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to the Obligor.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOIT IS THEREFORE ORDERED, ADJUDGED AND DECREED that no later than 30 days after the issuance of this order, the Obligee shall obtain health insurance coverage for the following child(ren):NameDate of BirthS. S. NumberGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomand furnish written proof to the Ashland County Child Support Enforcement Agency that the required health insurance coverage has been obtained.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.ALTERNATIVE 3: ORDER ON OBLIGOR AND OBLIGEE -R.C. 3119.30(D) The Court finds that health insurance is available at a reasonable cost to both the obligor and obligee and that dual coverage of both parents would provide for coordination of medical benefits without unnecessary duplication of coverage. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that within 30 days of the issuance of this order, both obligor and obligee provide health insurance coverage for the following child(ren):, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)NameS. S. NumberDate of BirthAttorney(s) forOffice and P.O. Addressand furnish written proof to the Ashland County Child Support Enforcement Agency that the required health insurance coverage has been obtained.Telephone No.: Facsimile No.: E-Mail Address:2Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)ALTERNATIVE 4: NEITHER PARTY HAS INSURANCE -R.C. 3119.30(C) The Court finds that health insurance is not available at a reasonable cost to either the obligor and obligee, and that both parties shall share liability for the cost of the medical and health care needs of their children. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the parties shall share all health care and medical expenses incurred for the benefit of the parties following minor child(ren):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NameDate of BirthS. S. NumberTHE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableIT IS FURTHER ORDERED, ADJUDGED AND DECREED, that the parties' respective share of all health care and medical expenses incurred for the children shall be paid pursuant to the terms of the Court's Local DR Rule 21, with the residential parent paying the first $100.00 per calendar year per child of any health care or medical expenses for the child(ren) for whom they are residential parent, together with % of the balance, and the non-residential parent paying % of the balance of
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