[YOUR NAME]
Indianapolis, IN 46201
[YOUR EMAIL]
222 555 7777
October 17, 2050

To Whom It May Concern:

I, [YOUR NAME], hereby declare and affirm the following regarding my separation from my spouse, Carmel Ryan.

On October 1, 2050, we mutually agreed to separate. This decision was made after careful consideration of our circumstances, and we believe it is in the best interest of both parties. Our separation is intended to be permanent.

As of this date, we have agreed on the following terms regarding our separation, particularly concerning health insurance and benefits:

1. Health Insurance Coverage: I confirm that I am currently enrolled in a health insurance plan provided by [YOUR COMPANY NAME]. It is understood that due to our separation, I will be responsible for maintaining my health insurance coverage as per the plan’s provisions.

2. Benefits: All benefits associated with my employment at [YOUR COMPANY NAME], including health insurance, will remain in effect until the policy’s next renewal period. I will ensure that my coverage remains uninterrupted and will notify [YOUR COMPANY NAME] of any changes in my marital status as required by company policy.

3. Contact Information: For any inquiries regarding my health insurance and benefits related to this separation, please contact me at [YOUR EMAIL] or 222 555 7777. Should there be a need for further documentation, I can be reached promptly.

I affirm that the information provided in this affidavit is true and accurate to the best of my knowledge. This affidavit serves as a formal declaration of our separation and the agreements outlined above regarding health insurance and benefits.

[YOUR NAME]
October 17, 2050

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