National Medical Support Notice Part B

NATIONAL MEDICAL SUPPORT PART B MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998 (CSPIA). Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established under such law. The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form, the Custodial Parent may also bet he employee when the State opts to enforce against the Custodial Parent. Issuing Agency: Office of the Attorney General Child Support Division - Medical Support Unit Issuing Agency Address: P.O. Box 1328 Austin, Texas 78767-1328 Notice Date: <F002> CSE Agency Case Identifier: <F003> Telephone Number: (800) 522-2421 FAX Number: (855) 329-6676 <F041> , <F042> , County, Texas Order Date: <F043> Order Identifier: <F040> Document Tracking Identifier:<F019> Employer web site: www.employer.texasattorneygeneral.gov See NMSN Instructions: www.acf.hhs.gov/programs/css/resource/national-medicalsupport-notice-form Court or Administrative Authority: ___________________________________________ Employer/Withholder's Federal EIN Number RE* ___________________________________________ Employee's Name (Last, First, MI) ________________________________________________ Employer/Withholder's Name __________________________________________ Employee's Social Security Number <F062> <F063> <F064> _____________________________________________________ Employer/Withholder's Address > <F027> <F028 __________________________________________ Employee's Mailing Address _____________________________________________________ Custodial Parent's Name (Last, First, MI) ___________________________________________ Substituted Official/Agency Name <F032> <F033> <F034> c/o P.O. Box 1328 Austin, Texas 78767-1328 Custodial Parent's Mailing Address ___________________________________________ ___________________________________________ ___________________________________________ Substituted Official/Agency Address (Required if Custodial Parent's mailing address is left blank) _______________________________________________________ Child(ren)'s Mailing Address (if different from Custodial Parent's) Office of the Attorney General, Child Support Division Telephone Number: (800) 522-2421 - Fax: (855) 329-6676 Name and Telephone Number of a Representative of the Child(ren) Medical Support Unit P.O. Box 1328 Austin, TX 78767-1328 Mailing Address of a Representative of the Child(ren) Child(ren)'s Name(s) <F068> <F071> <F074> <F077> <F080> Gender <F110> <F111> <F112> <F113> <F114> DOB <F069> <F072> <F075> <F078> <F081> SSN <F070> <F073> <F076> <F079> <F082> Child(ren)'s Name(s) <F083> <F086> <F089> <F092> <F095> Gender <F115> <F116> <F117> <F118> <F119> DOB <F084> <F087> <F090> <F093> <F096> SSN <F085> <F088> <F091> <F094> <F097> The order requires the child(ren) to be enrolled in [<F098>] all health coverages available; or [<F099>] only the following coverage(s): <F100> Medical; <F101> Dental; <F102> Vision; <F103> Prescription drug; <F104> Mental Health; <F105> Other (specify): <F106>_____________________________________________________________________________________________________________. THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB control number: 1210-0113. Expiration Date: 03/31/2016. Employer Name: <F061> Employer Federal EIN: <F054> Non-Custodial Parent: <F024> <F025> <F026> Non-Custodial Parent SSN: <F022> Bar Code (with FSN): <F019> FS#: <F019> OAG Case Number: <F003> Cause Number: <F040> Form 3N010 American LegalNet, Inc. www.FormsWorkFlow.com NMSN - Part B April 2014