Health Insurance Affidavit {DR-409}

DR-409 Page 1 of 2 Rev. COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO Case Number : Plaintiff/Petitioner 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 chi ld support. It must be filed if there are minor ch ildren of the relationship. If more space is needed, add additional pages. HEALTH INSURANCE AFFIDAVIT Affidavit of (Print Your Name) Your Spouse222s 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 organizatio n)? Yes No Yes No Does the available insurance cover primary care services within 30 miles of the child(ren)222s home? Yes No Yes No American LegalNet, Inc. www.FormsWorkFlow.com DR-409 Page 2 of 2 Rev. Your Spouse222s Under the available insurance, what would be the annual premium for a plan covering you and the child 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 child 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 of this relationship? Yes No Yes No Number Number Other individuals? Yes No Yes No Number Number Name of employer or organization that provides health insurance Address Phone number OATH (Do not 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 are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your S ignature Sworn before me and signed in my presence this day of , . Notary Public My C ommission E xpires: American LegalNet, Inc. www.FormsWorkFlow.com