Free foc13a.pmd - Michigan

Approved, SCAO

Original - Friend of the court 1st copy - Obligor 2nd copy - Requesting party

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Court address

CASE NO. COMPLAINT AND NOTICE FOR HEALTH-CARE EXPENSE PAYMENT
Telephone no.

Plaintiff

v

Defendant

TO:

Obligor's name and address

COMPLAINT I request the friend of the court to enforce health-care expenses. Attached is the request for health-care expense payment (including all supporting documents) given to the obligor. I declare that: 1. I requested payment within 28 days of the date notified of the balance due after insurance payments. 2. This request is for expenses that are more than the annual ordinary medical amount that can be collected as specified in the support order. health-care expenses that have been incurred by the payer of support. 3. This complaint is within six months after the date of the insurer's final denial of coverage for the expense. within one year of the date the expense was incurred. within six months after the obligor's default of an agreement to repay (copy of agreement attached). 4. As of this date, the expense information in the attached request for health-care expense payment is true except as follows: Since the date I mailed the request for health-care expense payment to the obligor, the obligor paid $ for and .
Name(s) of child(ren) Name(s) of medical provider(s)

Date

Signature

NOTICE The friend of the court has been asked to enforce health-care expenses. Unless you file a written objection with the friend of the court within 21 days of the date this notice is sent, the expenses will be added to your support account as a health-care support arrearage for enforcement and must be paid in full by . $ per month, except that the full balance will be subject to immediate enforcement. If you timely file a written objection in the manner required, a hearing will be set to resolve the health-care complaint.

CERTIFICATE OF MAILING I certify that on this date I served a copy of this complaint on the parties or their attorneys by first-class mail addressed to their lastknown addresses as defined in MCR 3.203.
Date Friend of the court/Authorized representative

FOC 13a (3/09)

COMPLAINT AND NOTICE FOR HEALTH-CARE EXPENSE PAYMENT

MCL 552.511a