nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnDIVISIONCOUNTY OHIOPlaintiffPetitioner 1vsandCaseNoJudgeMagistrateDefendantPetitioner 2HEALTH INSURANCE AFFIDAVITPlaintiffPetitioner 1DefendantPeti ID: 894647
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n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n ��Supreme Court of OhioUniform Domestic Relations Form Affidavit 4 HEALTH INSURANCE AFFIDAVITApproved under Ohio Civil Rule 84 Amended:June 1, 2021Page of DIVISION COUNTY, OHIO Plaintiff/Petitioner 1vs./and CaseNo. Judge Magistrate Defendant/Petitioner 2HEALTH INSURANCE AFFIDAVIT Plaintiff/Petitioner 1 Defendant/Petitioner 2 Is/are your child(ren) currently enrolled in a governmentprovidedprogram (i.e. Healthy Start/ Medicaid)? Yes Yes Is/are your child(ren) enrolled in an individual (nongroup or COBRA) health insurance plan? Yes Yes Is/are your child(ren) enrolled in a plan found through the exchange/Affordable HealthCare Marketplace? Yes Yes Is/are your child(ren) enrolled in a health insurance plan through a group (employer or otherorganization)? Yes Yes No If your child(ren) is/are not enrolled, does/do he/she/they (employer or other organization)? Yes Yes Does the available insurance cover primary care services within 30 miles of the children’s home? Yes Yes No Name of group (employer or organization) that provides health insurance AddressPhone Number _______________________ _____
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__________________ _______________________ _______________________ _______________________ _ _______________________ _______________________ InstructionsChecklocal court rules to determine when this form must be filed. This affidavit is used to disclose health insurance coverage that is available for childrenof the relationship. It is also used to determine child support. If more space is needed, add additionpages. ��Supreme Court of OhioUniform Domestic Relations Form Affidavit 4 HEALTH INSURANCE AFFIDAVITApproved under Ohio Civil Rule 84 Amended:June 1, 2021Page of OATH OR AFFIRMATION(Do not sign until NotaryPublicis present) (printname), swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurateand complete. I understand that if I do not tell the truth, I may be subject to penalties forperjury. __________________________________our Signature STATE OF _____________________) SSCOUNTY OF ___________________ Sworn to or affirmed before me by ________________________this _____dayof __________________________________________________Signature of Notary Public__________________________________Printed Name of Notary PublicCommission Expiration Date: __________Affix seal here PRIN