Fill and Sign the Support Order Form

IN THE ____________ COURT OF ___________COUNTY, ____________ NAME OF PLAINTIFF )       ) ) V. ) ) NO. ) ) NAME OF DEFENDANT )       ) ) QUALIFIED MEDICAL CHILD SUPPORT ORDER THIS ACTION came on for hearing on the ____ day of _______________, _____, upon the prayer of _______________________________ ("Plaintiff"), for the entry of a QUALIFIED MEDICAL CHILD SUPPORT ORDER ("QMCSO"), and the Court finds that the relief prayed for should be granted, and further finds as the facts in support of the relief granted; 1. That Plaintiff and __________________________ ("Defendant") were divorced by Judgment of this Court rendered herein on the ____ day of _________________, ______; 2. That Defendant's: a. Social Security number is _____________________, b. Employer is _____________________________________, whose business address in _____________ County, __________, is ___________________, but whose address for the purposes of this QMCSO is _____________________________________________________, c. Group health plan administered by _________________ _________________________________________________________________ (include policy number), and - 1 - d. Address is ________________________________________. 3. That Defendant is the natural father of __________________, BORN ______________, SOCIAL SECURITY NUMBER _____________, AND _________________ ________________, BORN ________________, SOCIAL SECURITY NUMBER ____________________, hereafter referred to as "the children"; and, 4. That Plaintiff, SOCIAL SECURITY NUMBER ______________, according to the terms of the said Judgment of Divorce, is the natural mother and custodial parent of the said children and resides with them at _________________________________________ ___________________________. IT IS, THEREFORE, ORDERED AND ADJUDGED that: 1. The children identified above shall be "Alternate Recipients" within the meaning of § 609 of the Employment Retirement Income Security Act of __74 ("ERISA"), codified at 29 U.S.C. § 1169, as amended, which was added by the Omnibus Reconciliation Act of 1993. 2. The said Alternate Recipients shall be enrolled in the Plan(s) effective the ____ day of ______________, _____, and are to receive all medical, dental, vision and other health benefits available to a dependent under any of the employer's group available to Defendant/Participant; the children shall receive the coverage that they would be entitled to receive under the Plan(s) as if they met all the requirements of a "dependent" and thus were dependents under the Plan(s); and, any benefits to which the Alternate Recipients become entitled by reason of this Order which are payable in cash, check or otherwise to the Alternate Recipients or to the Defendant with respect to the Alternate Recipients shall be paid instead to the Alternate Recipients' custodial parent, ____________________________________, the Plaintiff named hereinabove. - 2 - 3. Defendant is to make such elections and to consent to such withholding and deductions from pay or otherwise make required payments as might be necessary in order for the coverage required by this Order to be maintained. 4. This Order applies to the said Health, Dental, Vision, Life & Accidental Death & Dismemberment Plan(s) and any successor plan(s) and applies to each Alternate Recipient for that period during which, the Alternate Recipients are dependents, or Alternate Recipients would have been eligible for or could have elected coverage under the Plan(s). 5. This Order shall be construed so as not to require the Plan(s) to provide any benefit to an Alternate Recipient that would not be available to a dependent under the Plan(s). 6. The parties shall promptly submit this Order to the Plan Administrator(s) for determination of its status as a QMCSO. 7. While this Order is in effect, the parties shall promptly notify the Plan Administrator(s); a. Their addresses if they are different or change from those set forth in this Order; b. Any change of address of any Alternate Recipient or custodial parent as set forth in this Order; c. The change in status of any Alternate Recipient under § 609 of ERISA; and, d. A change in custodial parent of an Alternate Recipient. 8. This Order is intended that it shall qualify as a QMCSO under § 609 of ERISA; and, this Court retains jurisdiction to amend this Order as might be necessary to establish or maintain its status as a QMCSO under § 609 of ERISA. SO ORDERED AND ADJUDGED this the ____ day of ________________, _____. _______________________________ CHANCELLOR - 3 - PREPARED BY: ___________________________________ ATTORNEY FOR WIFE (Attorney name, address, phone number and State Bar number) ____________________________________ ATTORNEY FOR HUSBAND (Attorney name, address, phone number and State Bar number) - 4 -