Health Insurance Disclosure Affidavit

IN THE FRANKLIN COUNTY COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH Case No. Judge v./and Magistrate Plaintiff/Petitioner Defendant/Petitioner Instructions: This affidavit is required to be filed in all actions for dissolution, divorce or legal separation involving minor children, any complaint for custody, support, paternity or answer or counterclaim thereto, and with all motions to establish or modify child support or health insurance coverage, pursuant to Local Domestic Rule 24 and Local Juvenile Rule 10. 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) Mother Are your child(ren) currently enrolled in a low-income government-assisted health care program (Healthy Start/Medicaid)? Are you enrolled in an individual (nongroup or COBRA) health insurance plan? Are you enrolled in a health insurance plan through a group (employer or other organization)? If you are not enrolled, do you have health insurance available through a group (employer or other organization)? Does the available insurance cover primary care services within 30 miles of the child(ren)'s home? Father Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No J-232 (Rev. 10-2010) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Mother 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? Your spouse? Minor child(ren) of this relationship? Other individuals? Name of group (employer or organization) that provides health insurance Address Phone number OATH (Do not sign until notary is present.) Yes Yes Yes Number Yes Number No No No No Father $ $ $ $ Yes Yes Yes Number Yes Number No No No No 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 Signature Sworn before me and signed in my presence this day of Notary Public My Commission Expires: , . J-232 (Rev. 10-2010) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com