Free STATE OF WYOMING - Wyoming

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

DWCD 15 Notice of Change in Employment and/or Dependent Health Insurance Coverage Revised July 2006 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.

DWCD 15 Notice of Change in Employment and/or Dependent Health Insurance Coverage Revised July 2006 Page 2 of 2