FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.10) STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES NOTICE OF ENROLLMENT OF CHILDREN IN HEALTH CARE COVERAGE Pursuant to T.C.A. §36-5-101(f) and the attached Order/Notice to Withhold Income for Child Support (also called an Order for Income Assignment, Income Assignment Order, Income Assignment or Assignment), your employer has been directed, to enroll the following child(ren) in your family healthcare plan offered by your employer: ____________________________ ____________________________ ____________________________ ____________________________ DOB __________ SSN:____________________ DOB __________ SSN:____________________ DOB __________ SSN:____________________ DOB __________ SSN:____________________ You may contest this Notice of Enrollment by filing a written request for an administrative hearing with the child support office shown above within fifteen (15) calendar days of the mailing date of this Notice and by filing a copy of your written appeal request with your employer within the same timeframe. If you do not file the request with your employer, the above-named child(ren) will be enrolled in any family healthcare coverage available to you through your employer even if your appeal is timely filed with the local child support office. The grounds for contesting the enrollment are limited to a mistake of identity or fact involving the action and the reasonableness of the cost of the insurance. If you contest this Notice of Enrollment within the above time limit, a hearing will be promptly set. If you fail to timely file a copy of your appeal of the Notice of Enrollment for health insurance coverage, your employer will enroll and continue the health care coverage for your child(ren) pending the appeal decision. You and your employer will be notified of the decision within forty-five (45) days of the date the Order/Notice to Withhold Income for Child Support (also called an Order for Income Assignment or Income Assignment), and the Notice or Enrollment contained on that form, was issued. If an unfavorable decision is rendered, you have a right to further appeal the decision as described in the Department’s hearing order following the decision. It is your responsibility to keep the Court Clerk and the Local Child Support Office informed of the name and address of your current employer, whether you have access to health insurance coverage, and if so, the health insurance policy information. You must also immediately notify the Court Clerk and the Local Child Support Office of any changes in, or any additional employment, including the name and address of the new employer. Your new employer will be notified of the Order for Income Assignment. Authority: T.C.A. §§ 4-5-202, 8-21-403,36-5-101(f), 36-5-116, 36-5-501, 36-5-1002, and 71-1-132(c); 42 U.S.C. §§ 651 et seq., 42 U.S.C §§ 652(a)(11), 654(9)(E), 654a(g)(1)(A)(ii), 654b(a), and 666(a)(8) and (b); 45 C.F.R. §§ 303.6(c)(1), 303.7, and 303.100; and United States Department of Health and Human Services Office of Child Support Enforcement Action Transmittal 04-05 (July 15, 2004). Administrative History: Original rule filed October 14, 1999; effective December 28, 1999. Amendment filed August 17, 2005; effective October 31, 2005. October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com