COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. HEALTH INSURANCE DISCLOSURE AFFIDAVIT FRANKLIN COUNTY COMMON PLEAS COURT No. : Calendar DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH : JUDICIAL SUBPOENA Plaintiff(s)NUMBER _____________________________ CASE ______________________________________ PLAINTIFF / PETITIONER -against- : COURT DATE _______________________________ SS# __________________________________ : CHILDREN SUBJECT TO SUPPORT ORDER: DOB: ________________________________ NAME: __________________________ DOB: __________ : ADDRESS: ___________________________ . _____________________________________ ............................... SS#:____________________________________ Defendant(s) : ...................... NAME: __________________________ DOB: __________ SS#:____________________________________ THE PEOPLE OF THE STATE OF NEW YORKNAME: __________________________ DOB: __________ _____________________________________ DEFENDANT / PETITIONER SS#:____________________________________ SS# __________________________________ NAME: __________________________ DOB: __________ DOB: ________________________________ SS#:____________________________________ TO GREETINGS: ADDRESS: ___________________________ NAME: __________________________ DOB: __________ WE COMMAND YOU, that excuses being laid aside, you and each of _____________________________________ all business and SS#:____________________________________ you attend before , the Honorable at the Court located at County of INSTRUCTIONS PART I: in room , on the day of , 20 , at o'clock in the noon, and at any recessed Please disclose all requested information as it pertains to you or adjourned date, to testify and give evidence as a witness in this action on the part of the YOUR NAME: ________________________________ EMPLOYER ADDRESS: ________________________ EMPLOYER:__________________________________ EMPLOYER PHONE: _______________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to _____________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result YOU CURRENTLY RECEIVING MEDICAID? ____ YES ___ NO / MEDICARE? _____ YES _____ NO ARE of your failure to comply. DO YOU HAVE FAMILY HEALTH INSURANCE AVAILABLE EITHER THROUGH YOUR EMPLOYER OR Witness, Honorable , one of the Justices ANOTHER GROUP OR ORGANIZATION? ____YES ___ NO Court in County, day of IS COVERAGE PRESENTLY IN EFFECT? of the , 20 ____YES ___NO WHO IS PRESENTLY COVERED? _________________________________ RELATIONSHIP ________________ (Attorney must sign above and type name below) _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ Attorney(s) for _________________________________RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ INSURER ________________________________________ PHONE _________________________________ ADDRESS _______________________________________ Office and P.O. Address POLICY/ GROUP #____________________________ Telephone No.: Facsimile No.: E-Mail Address: WHAT IS THE PREMIUM FOR FAMILY COVERAGE? $_____________________ PER month/year (circle one) Mobile Tel. No.: DO YOU PAY A PREMIUM FOR COVERAGE? _________ YES ____________ NO WHAT IS THE PREMIUM FOR INDIVIDUAL COVERAGE? $_____________________ PER month/year (circle one) (Page 1 of 3) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. HEALTH INSURANCE DISCLOSURE AFFIDAVIT : Calendar No. IS A HEALTH INSURANCE CARD AVAILABLE? __________ YES ___________ NO ARE INSURANCE CARDS REQUIRED FOR SERVICES? Plaintiff(s) __________ YES ___________ NO JUDICIAL SUBPOENA : -against- : DOES YOUR PLAN COVER HOSPITALIZATION? __________ YES ___________ NO : IS THERE A DEDUCTIBLE FOR SERVICES? IF YES, WHAT IS THE DEDUCTIBLE? __________ YES ___________ NO : $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO Defendant(s) : ...................................................... IF YES, WHAT IS THE CO-PAYMENT? $_________________ per VISIT/MONTH/YEAR (circle one) DOES YOUR PLAN COVER DOCTOR VISITS? __________ YES ___________ NO THE PEOPLE OF THE STATE OF NEW YORK IS THERE A DEDUCTIBLE FOR SERVICES? IF TOYES, WHAT IS THE DEDUCTIBLE? __________ YES ___________ NO $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? IF YES, WHAT IS THE CO-PAYMENT? __________ YES ___________ NO $_________________ per VISIT/MONTH/YEAR (circle one) GREETINGS: IS A PRESCRIPTION CARD AVAILABLE? __________ YES ___________ NO DOES YOUR PLAN INCLUDE VISION COVERAGE? __________ YES ___________ NO WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the __________ YES ___________ NO Court IS THERE A CO-PAYMENT REQUIRED? located at County of IF YES, WHAT IS THE CO-PAYMENT? in room , on the day of $_________________ per PRESCRIPTIONin the , 20 , at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action___________ of the on the part NO DOES YOUR PLAN INCLUDE DENTAL COVERAGE? __________ YES IS COBRA COVERAGE AVAILABLE?with this subpoena is punishable as a contempt of court __________ YES ___________ NO Your failure to comply (COVERAGE AVAILABLE TO YOU AFTER TERMINATION OF EMPLOYMENT OR MARRIAGE) and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result AT WHAT COST TO YOU? $_________________ per MONTH/YEAR (circle one) IF YES, of your failure to comply. Witness, Honorable INSTRUCTIONS PART II: , one of the Justices of the Please disclose all requested information as it pertains to the other party Court in County, day of , 20 NAME OF OTHER PARTY: _______________________________EMPLOYER:_______________________________ EMPLOYER ADDRESS: ________________________ EMPLOYER PHONE: ____________________ (Attorney must sign above and type name below) _____________________________________________ IS HE/SHE CURRENTLY RECEIVING MEDICAID? ____ YES ___ NO / MEDICARE? _____ YES _____ NO Attorney(s) for DOES HE/SHE HAVE FAMILY HEALTH INSURANCE AVAILABLE EITHER THROUGH HIS/HER EMPLOYER OR ANOTHER GROUP OR ORGANIZATION? ____YES ___ NO IS COVERAGE PRESENTLY IN EFFECT? ____YES ___NO Office and P.O. Address WHO IS PRESENTLY COVERED? _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ Telephone No.: _________________________________ RELATIONSHIP ________________ Facsimile No.: E-Mail Address: Mobile Tel. No.: _________________________________ RELATIONSHIP ________________ _________________________________RELATIONSHIP ________________ (PAGE 2 OF 3) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. HEALTH INSURANCE DISCLOSURE AFFIDAVIT : Calendar No. INSURER ________________________________________ PHONE _________________________________ : ADDRESS _______________________________________ POLICY/ GROUP #____________________________ JUDICIAL SUBPOENA Plaintiff(s) -against- : DOES HE/SHE PAY A PREMIUM FOR COVERAGE? _________ YES ____________ NO : WHAT IS THE PREMIUM FOR FAMILY COVERAGE? $_____________________ PER month/year (circle one) : WHAT IS THE PREMIUM FOR INDIVIDUAL COVERAGE?$_____________________ PER month/year (circle one) Defendant(s) : . . . . . . . . . . __________ YES ___________ NO ....... . ........ ......... .... .......... IS.A HEALTH .INSURANCE .CARD.AVAILABLE? . ARE INSURANCE CARDS REQUIRED FOR SERVICES? __________ YES ___________ NO THE PEOPLE OF THE STATE OF NEW YORK DOES HIS/HER PLAN COVER HOSPITALIZATION? __________ YES ___________ NO IS TO THERE A DEDUCTIBLE FOR SERVICES? IF YES, WHAT IS THE DEDUCTIBLE? __________ YES ___________ NO $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? GREETINGS: IF YES, WHAT IS THE CO-PAYMENT? __________ YES ___________ NO $_________________ per VISIT/MONTH/YEAR (circle one) WE PLAN COVER DOCTOR VISITS? DOES HIS/HER COMMAND YOU, that all business and excuses being laid___________ and each of you attend before __________YES aside, you NO , the Honorable at the Court IS THERE __________ YES ___________ NO located County of A DEDUCTIBLE FOR SERVICES? at in room , on the day of , 20 , at o'clock in the noon, and at any recessed IF YES, WHAT IS THE DEDUCTIBLE? $_________________ per VISIT/MONTH/YEAR (circle one) or adjourned date, to testify and give evidence as a witness in this action on the part of the IS THERE A CO-PAYMENT REQUIRED? IF YES, WHAT IS THE CO-PAYMENT? __________ YES ___________ NO $_________________ per VISIT/MONTH/YEAR (circle one) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the PRESCRIPTION CARD AVAILABLE? was issued for a maximum penalty of $50NO all damages sustained as a party on whose behalf this subpoena and __________ YES ___________ IS A result of your failure to comply. IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO Witness, CO-PAYMENT? IF YES, WHAT IS THEHonorable Court in County, , one $_________________ per PRESCRIPTION day of DOES HIS/HER PLAN INCLUDE DENTAL COVERAGE? of the Justices of the , 20 __________ YES ___________ NO DOES HIS/HER PLAN INCLUDE VISION COVERAGE? __________YES ___________ NO (Attorney must sign above and type name below) IS COBRA COVERAGE AVAILABLE? __________ YES ___________ NO (COVERAGE AVAILABLE TO HIM/HER AFTER TERMINATION OF EMPLOYMENT OR MARRIAGE) IF YES, AT WHAT COST TO HIM/HER? $_________________ per MONTH/YEAR (circle one) Attorney(s) for SIGNATURES MUST BE NOTARIZED _________________________________________ AFFIANT _________________________________________ Office and P.O. Address ATTORNEY FOR AFFIANT _________________________________________ SUPREME COURT NUMBER SWORN TO ME AND SUBSCRIBED IN MY PRESENCE, THIS ____________DAY OF ________________, 20___ _______________________________________________ NOTARY PUBLIC (page 3 of 3) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com