District Court Juvenile Court ___________________________ County, Colorado Court Address: In re: The Marriage of: The Union of: Parental Responsibilities concerning: ______________________________________________________ Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Case Number: COURT USE ONLY Phone Number: FAX Number: E-mail: Atty. Reg. #: Division Courtroom NOTICE TO EMPLOYER TO DEDUCT FOR HEALTH INSURANCE To: Name of Employer: ________________________________________________________________ Address of Employer: _______________________________________________________________ Pursuant to §14-14-112, C.R.S., you are required to enroll the child(ren) listed below, of the Obligor (and the Obligor, if required by plan) in the health insurance plan (medical dental insurance vision) offered by you for the Obligor's benefit. Any reference to health insurance shall apply to the types of insurance checked above. Name of Obligor: _______________________________________ Soc. Sec. No.: _____________________ Address: _______________________________________________________________________________ Full Name of Child Date of Birth Social Security Number You are required to deduct from the wages due the Obligor an amount sufficient to provide for premiums for health insurance for the Obligor and his/her child(ren). Premium payments are to be made directly to the insurance carrier. Please deduct for health insurance premiums before you deduct any amounts for child support pursuant to §13-54-104, C.R.S. If the Obligor is no longer employed by you, you shall promptly notify the Court in writing of the Obligor's last known address, social security number, and the name of the Obligor's new employer, if known. The Obligor's child(ren) shall be enrolled in the health insurance plan in which the Obligor is enrolled if the child(ren) can be covered under the plan. If the Obligor is not enrolled in a plan, the child(ren) shall be enrolled in the least costly plan otherwise available to the child(ren) regardless of whether the child(ren) was/were born out of wedlock, is/are claimed as a dependent(s) on the Obligor's federal or state income tax return, live(s) with the Obligor, or live(s) within the insurer's service area, notwithstanding any other provision of law restricting enrollment to persons who reside in an insurer's service area. JDF 1809 R7-13 NOTICE TO EMPLOYER TO DEDUCT FOR HEALTH INSURANCE © 2012, 2013 Colorado Judicial Department for use in the Courts of Colorado Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com This withholding shall take effect no later than the first pay period after 14 days from the date on which this Notice is mailed to you or from the date on which the Obligor submits an oral or written request to you, whichever occurs sooner. The deduction for health insurance is treated as a significant life change under open enrollment requirements. It is your responsibility to ensure that the child(ren) of the Obligor is enrolled in a health insurance plan and that premium payments are withheld and forwarded to the insurer. If you wrongfully fail to deduct health insurance premiums, you, the employer, may be liable for the amount of accumulated premiums that should have been withheld from the Obligor's wages. You shall not discharge, refuse to hire, or take disciplinary action against an employee because of the entry or service of this Notice. If you do, you may be found in contempt of court and the Obligor may bring a civil action against you for reinstatement, lost wages, costs, and attorney's fees. Compliance with this Notice shall not subject you to liability to the Obligor for wrongful withholding. As long as the Obligor is employed by you, this Notice shall not be terminated or modified, except upon one the following: 1. Written notice by the Court, Obligee, or the Delegate Child Support Enforcement Unit. 2. Written verification, provided by the Obligor to the employer, the employer determines that the child(ren) is/are enrolled in a comparable health insurance plan that takes effect no later than the effective date on which the child(ren) is/are no longer enrolled under your plan. 3. Elimination of family health insurance coverage for all employees. When enrollment is terminated for any of the above reasons, within 14 days, you shall send, to the location described on the premium notice, a written notice of cancellation of enrollment or a copy of the verification provided by the Obligor to the employer that the child(ren) is/are enrolled in a comparable plan. If the Obligor terminates employment, you must notify the Court, Obligee, or Delegate Child Support Enforcement Unit in writing within 14 days after termination, and provide, if known, the name of the Obligor's new employer. The Obligor may file an objection to this Notice with the Court or Delegate Child Support Enforcement Unit if the premium amount does not meet the definition of reasonable cost as provided in §14-10-115(10)(g), C.R.S. A premium that results in a child support order of $50.00 or less or that is 20% or more of the Obligor's gross income shall not be considered reasonable. CERTIFICATE OF MAILING I certify that on ____________________ (date), I sent the original Notice to Employer to Deduct for Health Insurance to the Obligor's employer by United States Mail, first class postage prepaid, addressed as follows: __________________________________________________________________________________________ __________________________________________________________________________________________ and I certify that I sent a copy of the Notice to Employer to Deduct for Health Insurance to the Obligor by United States Mail, first class postage prepaid, addressed as follows: _______________________________________________________________________________________ _______________________________________________________________________________________ and I certify that I filed a copy of the Notice to Employer to Deduct for Health Insurance with the Court. Date: ____________________________ ___________________________________ Signature (Obligee or Obligee's Representative) JDF 1809 R7-13 NOTICE TO EMPLOYER TO DEDUCT FOR HEALTH INSURANCE © 2012, 2013 Colorado Judicial Department for use in the Courts of Colorado Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com