Order Health Insurance And Expense

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Rev. 4/5/02Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONSGEAUGA COUNTY, OHIO:CASE NO.Plain tiff/Petitio ner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:JU DGE:Soc. Sec.#:THE PEOPLE OF THE STATE OF NEW YORK TOvs.::ORDER Defendan t/Petit ioner:(Health Insuran ce and Expense) O.R .C . 3119.30-.58GREETINGS:Soc. Sec.#:The Court has determ ined thatis the parent responsible for theWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorablehealth care of the following chil d(ren ):,The Court furth er finds that the following grouplocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomhealth insur ance and health care polic ies, con tracts, and plans are available at reasonable cost to the Obligor or Obligee: (Li st name of insurer, and contr act or poli cy number)Name of Plan /InsurerAvailable to:Poli cy /Contr act #Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,SECTION I. ORDER ON OBLIG OR (Alternative A)(Attorney must sign above and type name below)[ ]The Court finds that the Obligor under the child support order isand that theObligor should be order ed to obtain health insur ance coverage thro ugh Attorney(s) for(Nam e of Employ er or other group plan)AND that health insur ance coverage is not available at a more reasonable cost thro ugh a group health insur ance or health care poli cy , contr act or plan available to the Obligee.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:-1 -Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that no later than thirty (30) days afterCalendar No.the issuance of this order, the Obligor obtain health insur ance coverage for the following chil d(ren ): (nam e, D.O.B., SS#) and fur ni sh writt en proof to the Geauga County Child Support Division ("C.S.E.D.") that the requ ired health insur ance coverage has been obtained.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligor supply the Obligee withinformation regarding the ben efit s, limitations and exclusions of the health insur ance coverage, copies of any insur ance forms necessary to receive reimbursement, payment or other benefits under the health insur ance coverage, and a copy of any necessary insur ance cards; that the Obligor submit a copy of this order to the insur er at the time application is made to enroll the child(ren) and that the Obligor, no later than thirty (30) days after the issuance of this order, fur ni sh writt en proof to the C.S.E.D. that the foregoing orders have been complied with.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ORDER ON OBLIG EE (Alternative B)THE PEOPLE OF THE STATE OF NEW YORK TO[ ]The Court finds that the Obligee under the support order is; that the Obligeehas health insur ance coverage available to him /her thro ugh(Nam e of Employ er or Other Group Plan)And it is available to the Obligee at a more reasonable cost than health insur ance coverage available to the Obligor.GREETINGS:IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Obligee obtain healthinsur ance for the following chil d(ren ): (na mes, D.O.B. and SS#)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofIT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligee supply the Obligor witho'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roominformation regarding the ben efit s, limitations and exclusions of the health insur ance coverage, copies of any insur ance forms necessary to receive reimbursement, payment or other benefits under the health insur ance coverage, and a copy of any necessary insur ance cards; that the Obligee submit a copy of this order to the insur er at the time application is made to enroll the child(ren) and that the Obligee, no later than thirty (30) days after the issuance of this order, fur ni sh writt en proof to the C.S.E.D. that the foregoing orders have been complied with.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.ORDER ON BOTH OBLIG OR AND OBLIG EE DUAL COVERAGE (Alternative C), one of the Justices of the[ ]The Court finds that health insur ance coverage is available at a reasonable cost to the Obligor thro ughCourt in Witness, Honorableday of, 20 County,and to the Obligee thro ughand that dual coverage by both parentswould provide for coordination of medical benefits without unnecessary duplication of coverage.(Attorney must sign above and type name below)IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that within thirty (30) days of theissuance of this order, both Obligor and Obligee provide health insur ance coverage for the following chil d(ren ): (N am es, D.O.B., SS#)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:-2 -Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.IT IS FURTHER ORDERED, ADJUDGED AND DECREED that each parent supply the other parentCalendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)with information regarding the ben efit s, limitations and exclusions of the health in