COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO Case No. Plaintiff/Petitioner Judge v./and Magistrate Defendant/Petitioner Instructions: Check local court rules to determine when this form must be filed. 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)? 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 Adapted from Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 Health Insurance Affidavit Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com Father Mother 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)? $ $ 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? Yes Number No Number Yes No 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: Adapted from Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 Health Insurance Affidavit Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com