STATE OF WYOMING
) ) ss. COUNTY OF ____________ )
IN THE DISTRICT COURT _________________ JUDICIAL DISTRICT
________________________________ Plaintiff, vs. _______________________________ Defendant.
) ) ) ) ) ) ) ) )
Civil Action No. ____________________
NOTICE OF CHANGE IN EMPLOYMENT AND/OR DEPENDENT HEALTH INSURANCE COVERAGE ` TO: Clerk of District Court
The payor/employer in the above-captioned matter, hereby serves notice that the Obligor (person owing support) has terminated his/her employment with the below-signed employer. In support thereof, the employer hereby states: 1. 20 . 2. The last known address of the obligor/employee is: The obligor/employee terminated his/her employment on the day of _____,
3.
The name and address of the employee's new employer is: (if known)
AND/OR
DWCP 22 Notice of Change in Employment and/or Dependent Health Insurance Coverage Revised July2006 Page 1 of 2
The payor/employer in the above-captioned matter hereby serves notice that the obligor/employee has had a change in his/her dependent health care coverage. Please describe the change in coverage:
Such change is/was effective as of the
day of
, 200 .
RESPECTFULLY SUBMITTED this ______ day of _______________________, 20______.
Employer/Former Employer Print Name: Address: Phone Number:
*File with the Clerk of District Court and mail a copy to the plaintiff or the plaintiff's attorney (if one) and to the defendant or the defendant's attorney (if one) at the last known address.
DWCP 22 Notice of Change in Employment and/or Dependent Health Insurance Coverage Revised July2006 Page 2 of 2