Fill and Sign the Divorce with Children of Marriage Packet Southeastern Ohio Form

COURT OF COMMON PLEAS COUNTY, OHIO Case No. Plaintiff/Petitioner 1 Judge v./and Magistrate Defendant/Petitioner 2 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) ________________ Your Name ______________ Spouse’s Name 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 (non - group 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 Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 Health Insurance Affidavit Approved under Ohio Civil Rule 84 Amended: March 15, 2016 Page 1 of 2 _______ _______ _ Your Name ______ ________ Spouse’s Name 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 Number Other individuals? Yes No Yes No Number Number Name of group (employer or organization) that provides health insurance Address Phone number O AT H ( Do no t 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 ar e true, accurate , and complete. I understand that if I do not tell the truth, I may be subject to penalties f or perjury. Your Signature Sworn before me and signed in my presence this day of , . Notary Public My Commission Expires: Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 Health Insurance Affidavit Approved under Ohio Civil Rule 84 Amended: March 15, 2016 Page 2 of 2