Fill and Sign the Ms Child Support Form

IN THE CHANCERY COURT OF       COUNTY, MISSISSIPPI RE: THE DISSOLUTION OF THE MARRIAGE OF       AND       CAUSE NUMBER       QUALIFIED MEDICAL CHILD SUPPORT ORDER WHEREAS, a Decree of Divorce terminating the marriage of the above - named parties was entered on             ,       , which decree incorporated a Medical Child Support Order that was approved by this Court on the same date; and WHEREAS, the Respondent is a participant in an employer - sponsored group health insurance plan (the Plan) where under the dependent children described below in this order are beneficiaries; and WHEREAS, the Petitioner, as the parent and legal guardian of the dependent children described below in this order, has requested the entry of a Qualified Medical Child Support Order by this court providing for group health insurance benefits for the dependent children described below in this order in accordance with the provisions of section 609 of the Employee Retirement Income Security Act ERISA), as amended; and WHEREAS,       , the Respondent, is a "participant," as that term is defined in 29 U.S.C. 1002(7), with respect to the Plan; and WHEREAS,       and       , the dependent children of the Respondent, are "alternate recipients," as that term is defined in 29 U.S.C. I 169(a)(2)(C), with respect to the Plan. Now Therefore, upon the request of counsel, THE COURT HEREBY FINDS AND ORDERS AS FOLLOWS: 1. Authority For Order. This Order is entered pursuant to the authority granted in the applicable domestic relations laws of the State of Mississippi. 2. Identification of Plan. The name and identification of the group health plan to which this Order relates and applies is as follows: Name of Plan:       Name of Plan Sponsor:       Identification No. of Plan:       Name and Address of Insurance Carrier:       Name and Address of Plan Administrator:       The group health plan described in this paragraph is referred to in this Order as "the Plan." 3. Identification of Participant. The following information is hereby established and reported with respect to the Participant: Name       Address       Birth Date       Social Security Number:       Term of Employment:       Employment Status:       Name, Address and Telephone No. of Attorney:       4. Identification of Alternate Recipients. The following information is hereby established and reported with respect to each Alternate Recipient: Name:       Address:       Birth Date:       Social Security Number:       Name:       Address:       Birth Date:       Social Security Number:       Name. Address and Telephone No. of Attorney:       5. Function to Which Order Relates. This Order relates to the provision of medical insurance benefits by the Participant for the benefit of the Alternate Recipients, who are dependent children of the Participant. 6. Right of Alternate Recipients to Receive Benefits: The right of the Alternate Recipients to enroll and receive medical insurance benefits under the Plan with respect to the Participant is hereby created and recognized. 7. Relationship of Alternate Recipient to Participate: The Alternate Recipients are dependent children of the Participant. 8. Intention of Order. This Order is intended to be a Qualified Medical Child Support Order as that term is defined in 29 U.S.C. 1 169(a)(2)(A). This Order is not intended to require, and shall not be construed so as to require, the Plan to provide any type or form of benefit, or any option, not otherwise provided under the terms of the Plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in section 1908 of the Social Security Act. 9. Type of Coverage for Alternate Recipients' Benefits: The type of coverage to be provided by the Plan to each Alternative Recipient, or the manner in which the type of coverage is to be determined, is as follows: 10. Beginning Date of Alternate Recipients' Benefits: The Plan shall enroll the Alternate Recipients as beneficiaries under the Plan with the coverage described in the preceding paragraph of this order as soon as administratively feasible after the approval of this Order by the plan administrator. Payment for the coverage shall be made by deduction from the Participant's wages, salary, or other compensation. 11. Period of Alternate Recipients' Benefits. Coverage for each Alternate Recipient shall continue until the first to occur of the following events with respect to each Alternate Recipient: (a) The Alternate Recipient becomes ineligible under the Plan because of age, (b) The Alternate Recipient is no longer eligible under the Plan due to a superseding order duly served on the Plan. or (c) The Alternate Recipient elects to terminate coverage under the Plan. The Participant may not elect to discontinue coverage under the Plan for any Alternate Recipient. 12. Survivor Coverage. The Participant shall elect to have the Alternate Recipients receive health care coverage under the Plan following the death of the Participant, whether or not the Participant has retired. 13. Reimbursement. If benefits payable to an Alternate Recipient under this Order are wrongfully or mistakenly paid by the Plan to the Participant, the Participant shall promptly reimburse the Alternate Recipient for such benefits by paying directly to the Alternate Recipient an amount equal to the benefits wrongfully or mistakenly received. 14. Determination of Qualified Status. A copy of this Order shall be delivered to the Plan Administrator who shall promptly notify the Participant and the Alternate Recipients of its receipt. Upon determining, within a reasonable time, the qualified status of this Order, the Plan Administrator shall promptly notify the parties of that determination. Should this Order be determined to be qualified, the Plan Administrator shall thereafter carry out the provisions of this Order. 15. Maintaining Qualified Status. It is the intention of the court and the parties that this Order continue to qualify as a Qualified Medical Child Support Order under 29 U.S.C. 1169 and any regulations that have been or may be issued there under. If changes are subsequently made in any statute or regulation affecting the qualified status of this Order, this Order shall be promptly modified upon the request of any party or the Plan Administrator so as to maintain its qualified status. 16. Successor Plans or Sponsors. Should the Plan, the sponsor, or the insurance carrier be replaced for any reason by a successor plan, sponsor. or insurance carrier this Order and the Alternate Recipients' rights there under shall apply equally to any successor plan, sponsor, or insurance carrier. 17. Continued Jurisdiction. The Court shall retain jurisdiction with respect to this Order to the extent required to retain the qualified status of the Order and to interpret and carry out the provisions of the Order. SO ORDERED on this the       day of       ,       . _______________________________________ CHANCELLOR