Fill and Sign the Minnesota Child Support 497312371 Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF __________ __________ JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. __________ __________ , Petitioner, QUALIFIED MEDICAL CHILD SUPPORT ORDER AND __________ , Respondent, 1. This order is intended to be a Qualified Medical Child Support Order under Section 609(a) of the Employee Retirement Income Security Act of 1974, as amended. This Order supersedes all previously filed Orders in this matter relating to this subject. 2. PLAN: This Order applies to the following group health care benefits plans sponsored by Employer's Name . Medical Plan Dental Plan (List Others) 3. PARTICIPANT: The employee named in this paragraph ("Participant") is a participant in the Plans identified above. The name, address, and Social Security number of the Participant are as follows: Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ 4. ALTERNATE RECIPIENTS: Name: _______________________________ - 1 - Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ 5. TYPE OF COVERAGE: The Alternate Recipients shall receive the following benefits under the Plans identified above: Medical Plan: Family coverage under the _____________ option presently available. Dental Plan: Family coverage under the _____________ option presently available. Other: {Describe} . If the above Plans are changed so that the benefits described in this paragraph are no longer available, the Alternate Recipients shall be entitled to family coverage under the most comparable (taking into account deductibles, co-payments, limitations on benefits, and type of benefits) plan offered by the Plan sponsor. - 2 - 6. DURATION: The coverage of the Alternate Recipients under the Plans will begin immediately upon qualification of this Order as a Qualified Medical Child Support Order and shall continue as long as both the Participant and each Alternate Recipient remain eligible for such coverage under the terms of such Plans. This order shall lapse as it applies to each Alternate Recipient upon said Alternate Recipient attaining the age of 18 (18) or age twenty (20) if the child is still attending high school, or until the minor child is emancipated, self - supporting, married, in the armed services of the United States, deceased, or until further Order of the Court, whichever first occurs. 7. PAYMENT INFORMATION: Unless assigned to the providers of the health care services, the Plans will make all payments of benefits for services rendered to an Alternate Recipient to: ? The Alternate Recipient ? The Alternate Recipient's custodial parent: Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ The Alternate Recipient's legal guardian: Name: _______________________________ Address: _______________________________ _______________________________ _______________________________ Social Security No.: _______________________________ Date of Birth: _______________________________ The Plans and their administrators are authorized to disclose all information about the benefits of the Alternate Recipients to the individual designated in this paragraph. 8. PREMIUMS: The Participant shall pay all premiums required to the coverage of the Alternate Recipients under the Plans while this Order remains in effect. Name of employer and/or its subsidiaries, and their successors shall withhold from the Participant's payroll checks the amount necessary to make such premium payments. 9. DETERMINATION BY PLAN ADMINISTRATORS: - 3 - The Alternate Recipients or their custodial parent or legal guardian shall deliver a signed copy of this Order to the Plan Administrator. For the purpose of determining whether this Order is a Qualified Medical Child Support Order, the Plan Administrator is advised that this Order provides for health benefit coverage with respect to a child of a participant under a group health plan, relates to benefits under such a plan and is made pursuant to the domestic relations law of this State. 10. CONTINUED JURISDICTION: In the event the Plan Administrator determines that this Order is not a Qualified Medical Child Support Order, both parties shall cooperate with the Plan Administrator to make the changes necessary for it to become a qualified order. This includes signing all documents which may be necessary for the parties to obtain an amended order meeting the requirements for a Qualified Medical Child Support Order. For this purpose, this Court expressly reserves jurisdiction over the dissolution proceeding involving the parents of the Alternate Recipients. 11. LIMITATIONS ON ORDER: Nothing in this Order shall be deemed to require the Plans to provide any type or form of benefits, or any option, not otherwise provided under the Plans. Based upon the foregoing, the Court issues this Order this ___ day of _________, 20__ ___________________________________ {Name of Judge} - 4 -