RULES OF CIVIL PROCEDURE - Supreme Court

COURT OF COMMON PLEASCOUNTY, OHIOPlaintiff/Petitionerv./andCase No.JudgeMagistrateDefendant/PetitionerInstructions: 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 childsupport. It must be filed if there are minor children of the relationship. If more space is needed, add additional pages.Affidavit ofHEALTH INSURANCE AFFIDAVIT(Print Your Name)MotherFatherAre your child(ren) currently enrolled ina low-income government-assistedhealth care program (HealthyStart/Medicaid)? Yes No Yes NoAre you enrolled in an individual (nongroupor COBRA) health insuranceplan? Yes No Yes NoAre you enrolled in a health insuranceplan through a group (employer orother organization)? Yes No Yes NoIf you are not enrolled, do you havehealth insurance available through agroup (employer or otherorganization)? Yes No Yes NoDoes the available insurance coverprimary care services within 30 milesof the child(ren)’s home? Yes No Yes NoSupreme Court of OhioUniform Domestic Relations Form – Affidavit 4Health Insurance AffidavitApproved under Ohio Civil Rule 84Effective Date: July 1, 2010 Page 1 of 2