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Affidavit of Health Care Expenses Mn Form
Information, and belief the following is a list of the joint
child(ren)’s unreimbursed or uninsured health care expenses for which the other parent has
not paid his/her full share:
Name of Joint Child
Who Received the Care
Date Care
Was Provided
(Limited to
costs within
the past 2
years)
Name of Provider
(doctor, dentist, clinic,
hospital)
If you need more space, add additional sheets of paper.
FAM403
State
ENG
5/11
www.mncourts.gov/forms
Description of
Medical/Dental...
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