IN THE COURT OF COMMON PLEASRevised 3/22/01 DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO ) CASE NO. ) ) JUDGE BETH A. SMITH SSN: ) DOB: ) EMPLOYER: ) ) PLAINTIFF ) ) REQUEST FOR AFFIDAVIT ORDER VS.)PURSUANT TO RULE 75(N) ) ) ) ) SSN: ) DOB: ) EMPLOYER: ) ) DEFENDANT)Now comes being first duly sworn, and requests that temporary orders be issued by Affidavit pursuant to Civil Rule 75(N) and Local Rule 10 based on the following: [check and complete those that apply] 1. Plaintiff and Defendant have lived in separate residences since .2. The Affiant requests an order for: child support; allocation of household expenses and debts; and/or spousal support.3. There are /are no/ minor children born or adopted of this marriage.4. I request that the Court designate me as temporary Residential Parent and Legal Custodian of the following minor child(ren): 1.DOB 4. DOB 2.DOB 5. DOB 3.DOB 6. DOB5. I consent that the Court designate my spouse as temporary Residential Parent and Legal Custodian of the above children.6. The minor child(ren) has /have/ resided solely with me / with my spouse/ since.7. The children reside in the marital home at.18. The children were removed from the marital home on , 20. 9. The minor child(ren) has/have the following physical, mental or emotional disabilities: . 10. I request the following companionship schedule:a. The Court's Local Parenting Time Schedule. b. The Court's Long Distance Parenting Time Schedule. c. Supervised or restricted parenting time for the following reasons: (attach additional page if necessary)11. There has /has not/ been any involvement of any child of these parties with a Children's Service Board or similar agency within the last 5 years.12. A civil or criminal action has /has not been/ filed by one party against the other arising out of an incident or allegation of domestic violence, child abuse, dependency or neglect. If such an action has been filed: Name the Court: . Name the Children's Services Board involved: . How was the matter resolved? .13. I am employed full-time/part-time. (If part-time state reason) .14. My spouse is employed full-time/part-time. (If part-time state reason) .15. I am not employed or cannot continue to be employed because .16. I was last employed on . I had gross income of per hour/ week/ year.17. If you are requesting an allocation of debts and expenses during pendency, how do you propose the debts/expenses be allocated and why? Are there certain debts and expenses that one party has usually paid? Please explain: (This Request for Affidavit Order may be supplemented by additional memoranda.)18. If you are requesting temporary spousal support, how much are you requesting per month?219. Other comments: STATE OF OHIO)SS: COUNTY OF MAHONING) herein, being first duly sworn, says that the facts stated herein are true as she/he verily believes.Plaintiff/DefendantSworn to and subscribed before me and in my presence this day of , 20.Notary Public Respectfully submitted Attorney / Party AddressTelephone No.NOTICE OF RIGHT TO FILE RESPONSE TO REQUEST FOR AFFIDAVIT ORDER A Counter Request for Affidavit Order or Affidavit of Income, Expenses and Financial Affidavit may be filed within fourteen (14 days) of being served with this Request. Unless previously filed, any Counter Request shall be accompanied by the Court's Affidavit of Income, Expenses and Financial Disclosure, Parenting Affidavit and IV-D Application (forms are available at the Domestic Relations Court). Any party filing a responsive document as described above shall take a copy of the document(s) to the Domestic Relations Assignment Commissioner so that it may be considered by the Magistrate at the non-oral hearing on affidavit orders.CERTIFICATE OF SERVICEI hereby certify that a copy of the foregoing Request for Temporary Orders has been served by Regular U.S. Mail upon this day of , 20 .Attorney/Party3
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