Complaint For Health Care Expenses {FD-FOC 4045}

STATE OF MICHIGAN THIRD JUDICIAL CIRCUIT COURT WAYNE COUNTY FRIEND OF THE COURT DEMAND FOR HEALTH CARE PAYMENT CASE NUMBER FRIEND OF THE COURT, P.O. BOX 31-2660, DETROIT, MI 48231-2660 Plaintiff Defendant To: Obligor's name and address Please provide dependents' date of birth and Social Security Number below. Child Child DOB DOB SSN______________ SSN______________ Child____________ _DOB_________SSN________ ______ Child_____________ DOB_________SSN________ ___ To the obligor: The following expenses have been submitted to the Friend of the court for enforcement. This notice is a demand for payment of the listed health care expenses. Contact the Obligee or Provider and arrange for payment within 14 days. Date of Service Physician/Provider Child Total Cost Amount paid by insurance Amount paid by obligee Balance due Provider I declare that the above (and any attached) statements of past-due health care expenses for the minor child(ren) are the true amounts not covered by insurance to the best of my information, knowledge and belief. ___________________________________ ____ ______________________________ Date Signature of Obligee __________________________ ___________________________________________________________________ This section for Friend of the Court use only Total health care cost not paid by insurance: Minus applicable annual ordinary health care cost: Percentage to be paid by obligor per judgment: Total amount due obligee and providers by obligor: $__________ $__________ __________% $__________ Date of mailing by court: _________ ___________________________ __ Senior Domestic Relations Specialist Phone: (313) - GRAND TOTAL (of all forms) FD/FOC4045 (01/07) $__________ DEMAND FOR HEALTH CARE PAYMENT (Page 1) American LegalNet, Inc. www.FormsWorkflow.com STATE OF MICHIGAN THIRD JUDICIAL CIRCUIT COURT WAYNE COUNTY FRIEND OF THE COURT DEMAND FOR HEALTH CARE PAYMENT CASE NUMBER Plaintiff Defendant Date of Service Physician/Provider Child Total Cost Amount paid by insurance Amount paid by obligee Balance due Provider ___________________________________ Date ____ ______________________________ Obligee's signature FD/FOC4045 (01/07) DEMAND FOR HEALTH CARE PAYMENT (Page 2) American LegalNet, Inc. www.FormsWorkflow.com