Mother
Father
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?
Yes No Yes No
Your spouse?
Yes No Yes No
Minor child(ren) of this
relationship?
Yes No Yes No
Number
Number
Other individuals?
Yes No
Yes No
Number
Number
Name of group (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 Signature
Sworn before me and signed in my presence this day of , .
Notary Public
My Commission Expires:
Supreme Court of Ohio
Uniform Domestic Relations Form – Affidavit 4
Health Insurance Affidavit
Approved under Ohio Civil Rule 84
Effective Date: July 1, 2010
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