Statement of Health Insurance Availability

This statement is made by _____________________________________________, Petitioner.

1. Child(ren)

The following child(ren) are the subject of this suit:

Name: ____________________________________________________ Birth date: ______________________________ Social Security number: ___________________

2. Health Insurance Availability

A. _______ Private health insurance is in effect for the child(ren).

Name of insurance company: _________________________________________

Policy number: _________________________________________

Party responsible for premium: _______________________________

Monthly cost of premium: __________________

(1) _______ The insurance coverage is provided through a parent's employment.

(2) _______ The insurance coverage is not provided through a parent's employment.

B. _______ Private health insurance is not in effect for the child(ren).

(1) _______ The child(ren) are receiving Medicaid benefits under chapter 32, Human Resources Code.

(2) _______ The child(ren) are not receiving Medicaid benefits under chapter 32, Human Resources Code.

(3) _______ The child(ren) are receiving health benefits coverage under the Children's Health Insurance Program under chapter 62 of the Texas Health and Safety Code. The cost of the premium is $____________.

(4) _______ The child(ren) are not receiving health benefits coverage under the Children's Health Insurance Program under chapter 62 of the Texas Health and Safety Code.

(5) _______ ____________________________________, mother of the child(ren), has access to private health insurance at reasonable cost to her.

(6) _______ ____________________________________, mother of the child(ren), does not have access to private health insurance at reasonable cost to her.

(7) _______ ____________________________________, father of the child(ren), has access to private health insurance at reasonable cost to him.

(8) _______ ____________________________________, father of the child(ren), has access to private health insurance at reasonable cost to him.

(9) _______ ____________________________________ has applied for Medicaid benefits for the child(ren). The status of the application is _________________________________________________________________________.

(10) _______ ____________________________________ has applied for coverage for the child(ren) under the Children's Health Insurance Program. The status of the application is _______________________________________________________________.

Date: ________________________________.

___________________________________ Signature of Petitioner