Free FL-475* - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. PETITIONER/PLAINTIFF: :
RESPONDENT/DEFENDANT:

FL-475

Index No.

CASE NUMBER:

: Plaintiff(s) -against: : :

Calendar No.

EMPLOYER'S HEALTH INSURANCE RETURN 1. Name of parent employee: 2. Home address of absent parent employee: Not known

JUDICIAL SUBPOENA

3.

The employee has no insurance policies for health care, vision care, or:dental care through this employment.

4.

Defendant(s) : ......................................................

The employee has the following insurance policies covering health care, vision care, and dental care: Company Type of policy Policy No.

Persons insured

THE PEOPLE OF THE STATE OF NEW YORK TO
Date:

GREETINGS:
Address:

(TYPE OR PRINT NAME OF EMPLOYER)

(SIGNATURE OF EMPLOYER)

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Telephone No.: located at County of in roomcompleted returnthethe followingof child support agencyat , on to day local , 20 , within 30 days (name the address of local at any recessed o'clock in and noon, and child 5. Return this or adjourned date, to testify and give evidence as a witness in this action on the part of the support agency):
If any insurance coverage lapses, complete the notice below and return a copy to the same local child support agency.

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 NOTICE OF LAPSE IN HEALTH INSURANCE result of your failure to comply.
6. The health insurance listed on the Employer's Health Insurance Return above has lapsed terminated for (check one): a. all persons insured, for the following reason (specify):

Court in

Witness, Honorable County,

, one of the Justices of the , 20
for the following reason (specify): (Attorney must sign above and type name below)

day of

b.

the following person (name):

Attorney(s) for
Date:

(TYPE OR PRINT NAME OF EMPLOYER)

(SIGNATURE OF Office and P.O. Address EMPLOYER)

Address: Telephone No.:

Form Adopted for Mandatory Use Judicial Council of California FL-475 [Rev. January 1, 2003]

Telephone No.: Facsimile No.: E-Mail Address: EMPLOYER'S HEALTH INSURANCE RETURN Mobile Tel. No.:

Page 1 of 1 Family Code, §§ 3771, 3772 www.courtinfo.ca.gov

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