Motion To Show Cause For Non-Payment Of Support Form - Court Of Common Pleas, Cuyahoga County, Ohio Page 3

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STATE OF OHIO
)
)
SS:
AFFIDAVIT
CUYAHOGA COUNTY
)
I, ______________________________, having been first duly sworn according to law, hereby
state and depose that:
1.
I am the Obligee under the support order of this Court issued ____/____/20____;
Obligor should have paid $____________________in child support, cash medical support, and/or
spousal support, which includes 2% processing charge, since the commencement date of the order
through ____/____/20____;
Obligor paid $____________________ in child support, cash medical support, and/or spousal
support including the last payment received on ____/____/20____;
The arrearage is $____________________as of ____/____/20____;
2.
The order requires Obligor to pay _______% of health care expenses not covered or
reimbursed by private health insurance or cash medical support for the parties’ minor child(ren).
Obligor has failed to pay health care expenses not covered or reimbursed by private health
insurance or cash medical support for the parties’ minor child(ren) as ordered;
I have demanded payment of said expenses.
I have not demanded payment of said expenses.
An itemized list of said expenses is attached.
FURTHER AFFIANT SAYETH NAUGHT.
_______________________________________
SIGNATURE
Sworn to and subscribed before me this ________ day of __________________, 20____.
_______________________________________
NOTARY
NOTARY PUBLIC
SEAL
DR0900001 Motion to Show Cause for Nonpayment of Support

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