Uniform Domestic Relations Form – Affidavit 4 (Health Insurance Affidavit)

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Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 HEALTH INSURANCE AFFIDAVIT Approved under Ohio Civil Rule 84 Amended: June 1, 2021 Page 1 of 2 IN THE COURT OF COMMON PLEAS DIVISION COUNTY, OHIO Plaintiff/Petitioner 1 vs./and Case No. Judge Magistrate Defendant/Petitioner 2 HEALTH INSURANCE AFFIDAVIT Affidavit of ____________________________________ (Print Name) Plaintiff/Petitioner 1 Defendant/Petitioner 2 Is/are your child(ren) currently enrolled in a government- provided program (i.e. Healthy Start/ Medicaid)? Yes No Yes No Is/are your child(ren) enrolled in an individual (non- group or COBRA) health insurance plan? Yes No Yes No Is/are your child(ren) enrolled in a plan found through the exchange/Affordable HealthCare Marketplace? Yes No Yes No Is/are your child(ren) enrolled in a health insurance plan through a group (employer or other organization)? Yes No Yes No If your child(ren) is/are not enrolled, does/do he/she/they 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 children’s home? Yes No Yes No Under the available insurance, what is the annual premium you pay for family coverage? $ ________________ $ ________________ Name of group (employer or organization) that provides health insurance Address Phone Number _ _______________________ _ _______________________ _ _______________________ _ _______________________ _ _______________________ _ _______________________ _ _______________________ ________________________ 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 of the relationship. It is also used to determine child support. If more space is needed, add additional pages.

Supreme Court of Ohio Uniform Domestic Relations Form – Affidavit 4 HEALTH INSURANCE AFFIDAVIT Approved under Ohio Civil Rule 84 Amended: June 1, 2021 Page 2 of 2 OATH OR AFFIRMATION (Do not sign until Notary Public is present) I, (print name) , 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, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. __________________________________ Your Signature STATE OF _____________________ ) ) SS COUNTY OF ___________________ ) Sworn to or affirmed before me by ________________________this _____day of _______________, _________. __________________________________ Signature of Notary Public __________________________________ Printed Name of Notary Public Commission Expiration Date: __________ (Affix seal here)