Original - Court 1st copy - Friend of the Court 3rd copy - Defendant Approved, SCAO 2nd copy - Plaintiff 4th copy - Return STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT NOTICE OF NONCOMPLIANCE COUNTY (HEALTH CARE COVERAGE) Friend of the Court address FAX no. Telephone no. Plaintiff name, address, and telephone no. 1. Date of mailing: 2. The Office of the Friend of the Court has reviewed your files and determined that you, as plaintiff, defendant, have failed to obtain or maintain dependant health care coverage avail- able at a reasonable cost as ordered by the court. 3. Within 21 days after this notice is mailed, you must complete either the "Proof of Health Defendant name, address, and telephone no. Care Coverage" or the "Request for Hearing" below and send it to the friend of the court. 4. If you do not respond as required, the friend of the court office will notify your employer to deduct premiums for dependent health care coverage and will notify the insurer or plan administrator to enroll the child in dependent health coverage. 5. The order for dependent health care coverage will be applied to current and subsequent employers Check this box if you have proof of health care and periods of employment. coverage. Then: 1) complete this proof; and 2) photocopy your insurance card(s) and PROOF OF HEALTH CARE COVERAGEattach them to this proof. Return this proof and any attachments to the friend of the court. Medical insurance company name and address Group/Policy/Contract number Beginning date, if knownName of policy holder Dental insurance company name and address Group/Policy/Contract number Beginning date, if knownName of policy holder Optical insurance company name and address Group/Policy/Contract number Beginning date, if knownName of policy holder Individuals currently covered by your insurance Name Birthdate Relationship Medical Dental Optical (check) (check) (check)Date Signature Check this box if you want to request a hearing. Then date and sign the request and return it to REQUEST FOR HEARING the friend of the court. I request a hearing to show that health care coverage is not available at a reasonable cost. Date Signature FOC 3b (11/02) NOTICE OF NONCOMPLIANCE (HEALTH CARE COVERAGE) MCL 552.626