COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO Case Number: Plaintiff/Petitioner vs./and 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) Your Name Name Other Party’s 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 group or COBRA) health insurance plan? Yes No Yes No Are you enrolled in a health insurance plan through a (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 Yes No Yes No child(ren)’s home?
COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO Case Number: Plaintiff/Petitioner vs./and 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) Your Name Other Party’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 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