PURSUANT TO YOUR HEALTH CARE ORDER, YOU MUST PROVIDE VERIFICATION TO THE CHILD SUPPORT ENFORCEMENT AGENCY. FAILURE TO DO SO MAY RESULT IN A FINDING OF CONTEMPT. FAILURE TO COMPLY WITH THE HEALTH CARE ORDER MAY RESULT IN ADDITIONAL PENALTIES AS WELL. RETURN THIS FORM TO: HAMILTON COUNTY ENFORCEMENT AGENCY 222 E. CENTRAL PARKWAY CINCINNATI, OHIO 45202-1332 OR ATTACH TO YOUR DECREE OR AGREED ENTRY _____________________________________ Plaintiff / Petitioner ( ) Obligor ( ) Obligee Date Case No. File No. -vs/and- CSEA No. Judge ______________________________________ Defendant / Petitioner ( ) Obligor ( ) Obligee HEALTH CARE VERIFICATION (C.S.E.A.) ( ) Obligor ( ) Obligee ( ) Attorney Ins. Policy No. Insurer: Whereas, _____________________________(obligor/obligee) is ordered to obtain/maintain health coverage for the minor child(ren) and whereas O.R.C. §3119.31 imposes verification requirements upon the above named person, ____________________________________(obligor/obligee) hereby swears under penalty of contempt as follows: (1) I have obtained/am maintaining health insurance coverage as ordered. Said coverage is in full force and effect. (2) I have sent or will send contemporaneous with this affidavit, a copy of the health care order to the insurer. (3) (Obligor Only) - I have supplied Obligee with: a) insurance forms necessary to receive payment, reimbursement or other benefits; b) necessary insurance cards, and c) information regarding the benefits, limitations, and exclusions of the health insurance coverage. ________________________________________ Affiant Sworn to before me and subscribed in my presence by ____________________________________ this (Obligor/Obligee) ____________day of ____________________________, 20_____________. ______________________________________ Notary Public ************************************************* VERIFICATION *************************************************** Attorneys for Obligor and Obligee agree that the requirements of O.R.C. §3119.31 have been met and that notification to the Child Support Enforcement Agency is not required. Attorney for Obligor DR 7.21 (Revised 01/01/2003) Attorney for Obligee American LegalNet, Inc. www.FormsWorkFlow.com