COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO CASE NO. ________________ SETS NO. ________________ _________________________________ Plaintiff/Petitioner Judge ________________ V./and Magistrate __________________ Defendant/Petitioner Instructions: This affidavit is used to disclose health insurance coverage that is available for children. It is also used to determine child support. It must be filed if there are minor children of the relationship. If more space is needed, add additional pages. HEALTH INSURANCE AFFIDAVIT Affidavit of __________________________ (Print Your Name) Mother Father Are your child(ren) currently enrolled in a low-income government-assisted health care program (Healthy Start/Medicaid/CareSource/etc.)? □ Yes □ No □ Yes □ No Are you enrolled in an individual (nongroup or COBRA) health insurance plan? □ Yes □ No □ Yes □ No Are you enrolled in a health insurance plan through a group (employer or other organization)? □ Yes □ No □ Yes □ No If you are not enrolled, do you have health insurance available through a group (employer or other organization)? □ Yes □ No □ Yes □ No Does the available insurance cover primary care services within 30 miles of the child(ren)’s home? □ Yes □ No □ Yes □ No Under the available insurance, what would be the annual premium for a plan covering you and the child(ren) of this relationship (not including a spouse)? $ _______________ $ ______________ Under the available insurance, what would be the annual premium for a plan covering you alone (not including children or spouse)? $ _______________ $ ______________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Mother Father If you are enrolled in a health insurance plan through a group (employer or other organization) or individual insurance plan, which of the following people is/are covered: Yourself? □ Yes □ No □ Yes □ No Your spouse? □ Yes □ No □ Yes □ No Minor child(ren) of this Relationship? □ Yes □ No □ Yes □ No Number ______ Other individuals? Number ______ □ Yes □ Yes □ No □ No Number ______ Number ______ Name of group (employer or organization) that provides health insurance ___________________ ____________________ Address ___________________ ____________________ ___________________ ____________________ ___________________ ____________________ Phone number OATH [Do not sign until notary is present.] I, (print name), , swear or affirm that I have read this document and, to the best of my knowledge 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: _____________________________________ Rev. 7/2010 Form DR-409 American LegalNet, Inc. www.FormsWorkFlow.com