Fill and Sign the Mn Obtain Form

FORM 5A. NOTICE TO OBLIGOR OF MEDICAL SUPPORT ENFORCEMENT FORM 5A. NOTICE TO OBLIGOR OF MEDICAL SUPPORT ENFORCEMENT See Minn. Stat. § 518.171 ______________________________ ______________________________ NOTICE TO OBLIGOR OF MEDICAL SUPPORT ENFORCEMENT TO: ______________________________ ____________________ , OBLIGOR. You are hereby notified pursuant to Minnesota Statute 518.171, that thirty (30) days have passed since entry of the court order dated ______________________________ . You have failed to provide written proof that the required health and dental insurance has been obtained, or that an application for insurability has been made. If, after fifteen (15) days from the date of this notice, written proof that the insurance coverage exists is not received at the address listed below, a copy of the court order for insurance coverage will be forwarded to your employer or union. This order is binding on your employer or union. Upon receipt of the order, your employer or union will enroll the minor children named in the order as beneficiaries in an insurance plan and withhold any required premium from your income or wages. If more than one plan is offered by your employer or union, the children will be enrolled in the least costly plan otherwise available to you that is comparable to a number two qualified plan as defined by Minnesota Statute 62E.06, subdivision 2. The children will remain eligible for insurance coverage until emancipated or until further order of the court. If dependent health and dental insurance is available for the benefit of your (ex-) spouse at no additional cost, the employer or union will also enroll that person. If you fail to maintain the medical or dental insurance as ordered, you will be liable to the Obligee for any medical or dental expenses incurred from the date of the court order. Proof of failure to maintain insurance constitutes a showing of increased need by the Obligee pursuant to Minnesota Statute 518.64 and provides a basis for a modification of your child support order. Date: ______________________________ ________________________________________ (Address) (Address) (City, State, Zip) (Telephone Number)