Motion for Contempt and Affidavit

This affidavit must be executed if the other party violated a court order. If executed, this affidavit functions as a request for the Court’s enforcement of its order. As such, the other party should be held in contempt for her/his violation.Download

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Supreme Court of Ohio	 	Uniform Domestic Relations Form – 21 
Uniform Juvenile Form –  3  
MOTION FOR CONTEMPT AND AFFIDAVIT  
Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46  
Effective Date: 7/1/2013	 	Page 	1 of 2 	
 	
IN THE COURT OF COMMON PLEAS	 	
 	 	Division	 	
 	 	COUNTY, OHIO	 	
IN THE MATTER OF:	 	
 	 	
A Minor	 	
 	: 	 	
Name	 	: 	 	
 	: 	Case No.	 	 	
Street Address	 	: 	 	
 	: 	 	
City, State and Zip Code	 	: 	Judge	 	 	
Plaintiff/Petitioner	 	: 	 	
vs.	 	: 	 Magistrate	 	 	
 	: 	 	
Name	 	: 	 	
 	: 	 	
Street Address	 	: 	 	
 	: 	 	
City, State and Zip Code	 	
 
                               	Defendant/Petitioner	 	
: 	
 	
  
Instructions:	 This	 form 	is used 	to request the 	enforce	ment of	 a court order	 and	 hold 	the other	 party in contempt for 	
violati ng the court  order. A Request for Servi ce (Uniform Domestic Relations Form  28) and  a proposed Show Cause 
Order , Notice  and Instructions to  the Clerk (Uniform Domestic Relations Form  22)  must be filed with this Motion.  Check 
local court procedures.	 	
 	
MOTION FOR CONTEMPT AND AFFIDAVIT	 	
 
I, 	 	(na	me), request an order for	 	
 	(other party’s name) to appear and show cause 	 	
why he/she 	should not be held in 	contempt for violating a court order and 	a finding of	 contempt for violating 	 	
the court 	order 	regarding the 	following 	(check all 	that	 apply)	: 	
1. 	 Interference with parenting time or other parenting orders filed on                                    	 	 	(date).	 	
 	 	
2.   	 Failure to pay c	hild support	, as required by the order filed on  	  	(date)	 	
 	and the total arrearag	e owed is	  $ 	 	
 	(Bring to 	the hearing an 	up	-to-date 	printout from the 	County 	Child 	Support 	Enforcement Agency	 	
 	showing the amount of the child support owed to you.)	 	
 	 	
3.   	 Failure to pay s	pousal support	, as required by the order filed 	on	  	 (date)

Supreme Court of Ohio	 	Uniform Domestic Relations Form – 21 
Uniform Juvenile Form –  3  
MOTION FOR CONTEMPT AND AFFIDAVIT  
Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46  
Effective Date: 7/1/2013	 	Page 	2 of 2 	
 
 	and the total arrearage owed is	 $ 	 	
 	(Bring to the 	hearing an up	-to-date	 printout from the 	County Child Support 	Enforcement A	gency	  	
 	or other independent proof showing the amount owed to you.	) 	
 	 	
4. 	 Payment or reimburseme	nt of health care expenses incu	rred for the minor child(ren). 	Attach 	 	
 	an Explanation of Health Care Bills (	Uniform Domestic Relations 	Form 26) and bring to the hearing 	 	
 	the following documents:	 	
 	a. 	Copies of each bill f	or which you seek reimbursement;	 	
 	b. 	Proof of payment by you. Proof o	f payment may include a receipt for payment signed by the	 	
 	health care provider, a copy of a cancelled check, or a copy of a credit card statement	 	
 	verifying the amount paid;	 and	 	
 	c. 	Explanation of Benefits forms showing pay	ment made b	y the health insurance carrier.	 	
 	 	
5. 	 Failure to comply with the Court's orders of 	  	(date) regarding	 	
 	(check all that apply):	 	
 	 Transfer of real estate, as follows:    	  	
 	 Payment of debt,	 as follows: 	 	 	
 	 Refinance of debt, as follows:  	  	
 	 Distribution of personal property, as follows:  	  	
 	 Other (specify)	:    	
 
6. 	Costs and any other relief as necessary and proper are also requested.	 	
 	 	
 	Your Signature	 	
 	 	
 	
Telephone number at which the Court may reach you	 or 	
at which messages may be left for you	 	
 	 
OATH 	 	
(Do not sign until Notary is present.)	 	
 
I,   	(name), swear or affirm that I have read this document	 	
and, to the best of my know	ledge 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: