Fill and Sign the Notice to Obligor of Medical Support Enforcement Millerdavis Form

FO RM 5 A . N O TIC E T O O BL IG OR O F M ED IC AL SU PPO RT E N FO RCEM EN T FO RM 5 A . N OTIC E T O O BLIG OR O F M ED IC A L S U PPO RT E N FO RCEM EN T S ee M in n. S ta t. § 5 18.1 71__ _____ _______________ _________ _____________________________ N OTIC E T O O BLIG OR O F M ED IC A L S U PPO RT E N FO RCEM EN T TO : _ __________________ ____________ __________ _________, O BLIG OR. Y ou a re h ere b y n oti f ie d p urs u an t to M in neso ta S ta tu te 5 18.1 71, th at th ir ty (3 0) d ay s h av e pa sse d s in ce e n tr y o f th e c o u rt o rd er d ate d _ _________ ____________________. Y ou h av e f a ile d to p ro vid e w ritte n p ro of th at th e r e q uir e d h ealth a n d d en ta l in su ra n ce h as b een o bta in ed , o r th at a n ap plic atio n f o r i n su ra b ility h as b een m ad e.If, afte r fif te en (1 5 ) d ay s fro m th e d ate o f th is n otic e, w ritte n p ro of th at th e in su ra n ce co vera g e e x is ts is n ot r e ceiv ed a t th e a d dre ss lis te d b elo w , a c o py o f th e c o urt o rd er f o r in su ra n ce co vera g e w ill b e f o rw ard ed to y our e m plo yer o r u nio n . T his o rd er is b in din g o n y our e m plo yer o r un io n.U pon r e ceip t o f th e o rd er, y our e m plo yer o r u nio n w ill e n ro ll th e m in or c h ild re n n am ed in the o rd er as b en efic ia rie s in an in su ra n ce p la n an d w ith hold an y re q uir e d p re m iu m fro m y our in co m e o r w ag es. If m ore th an o ne p la n is o ffe re d b y y our e m plo yer o r u nio n, th e c h ild re n w ill b e en ro lle d in th e le ast c o stly p la n o th erw is e a v aila b le to y ou th at is c o m para b le to a n um ber tw o qu alif ie d p la n a s d efin ed b y M in neso ta S ta tu te 6 2E .0 6, s u bdiv is io n 2 . T he c h ild re n w ill re m ain elig ib le f o r i n su ra n ce c o vera g e u ntil e m an cip ate d o r u n til f u rth er o rd er o f t h e c o urt.I f d ep en den t h ealth a n d d en ta l in su ra n ce is a v aila b le f o r th e b en efit o f y our ( e x -) s p ouse a t no a d dit io nal c o st, t h e e m plo yer o r u nio n w ill a ls o e n ro ll t h at p ers o n.If y ou f a il to m ain ta in th e m ed ic al o r d en ta l in su ra n ce a s o rd ere d , y ou w ill b e lia b le to th e Ob lig ee fo r a n y m ed ic al o r d en ta l e x pen se s in cu rre d fro m th e d ate o f th e c o urt o rd er. P ro of o f fa ilu re to m ain ta in in su ra n ce c o nstitu te s a s h ow in g o f in cre ase d n eed b y th e O blig ee p urs u an t to Min neso ta S ta tu te 5 18.6 4 a n d p ro vid es a b asis f o r a m od if ic atio n o f y our c h ild s u pport o rd er. D ate : _ ______ __________ _____________ _ _ _____ _______________ __________________(A ddre ss)(A ddre ss)(C ity , S ta te , Z ip )(T ele p hone N um ber)