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Appendix B ­ Affidavit of Available Health Care Coverage

IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION BUTLER COUNTY, OHIO __________________________________ : Plaintiff/First Petitioner/Petitioner __________________________________ : __________________________________ vs. __________________________________ Defendant/Second Petitioner/Respondent __________________________________ __________________________________ : : : : : :::: Affidavit of Available Health Care Coverage CASE NO. ____________________

Affiant, __________________________________, being duly cautioned and sworn states as follows: ____ 1. Affiant states there is health insurance available for the parties' child(ren) through mother's employer private health insurance spouse. The cost of the insurance is $_________________________ per _______ for the family plan and $_____________________ per (state weekly, biweekly, bimonthly, monthly, annually) _______ for employee only coverage. The cost of the insurance is included in the child support calculation which affiant has filed with this affidavit. ____ 2. Affiant states there is health insurance available for the parties' child(ren) through father's employer private health insurance spouse. The cost of the insurance is $_________________________ per _______ for the family plan and $_____________________ per (state weekly, biweekly, bimonthly, monthly, annually) _______ for employee only coverage. The cost of the insurance is included in the child support calculation which affiant has filed with this affidavit. ____ 3. Affiant states there is health insurance available for the parties' child(ren) through mother's employer private health insurance spouse. Affiant does not have information or access to the information as to the cost of the coverage. Affiant has subpoenaed the information from the employer. ____ 4. Affiant states there is health insurance available for the parties' child(ren) through father's employer private health insurance spouse. Affiant does not have information or access to the information as to the cost of the coverage. Affiant has subpoenaed the information from the employer.

Appendix B ­ Affidavit of Available Health Care Coverage

____ 5. Affiant states there is no health insurance available through either parent's employer. The attached child support calculation includes a cash medical payment to be paid in addition to the child support order by the obligor in this case. ____ 6. Affiant states there is no health insurance available through either parent's employer. Affiant further states that the parties' children are covered by a state medical card with _____________________________________ as the custodian of the children. The attached child support calculation includes a cash medical payment to be paid in addition to the child support by the obligor in this case. ____ 7. Affiant states he/she has no knowledge as to whether there is health insurance available through the other parent's employer private health insurance spouse. The attached child support calculation provides for child support and a cash medical payment to be paid by the obligor if there is no coverage. OATH OF AFFIANT I hereby swear or affirm that the answers above are true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of the document may also subject me to criminal penalties for perjury (R.C. 2921.11). __________________________________________ Signature of Affiant ______________________________ Date

Sworn to and subscribed before me this _________ day of _____________________, ________. ____________________________________ Notary Public My commission expires ________________