IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: __________________________________, Petitioner and , Respondent ORDER FOR HEALTH INSURANCE COVERAGE TO: ALL EMPLOYERS (OR FUTURE EMPLOYERS), or any other person providing health insurance coverage for OBLIGOR{name of person who was or dered to provide health insurance} _______________________________________________________________________: YOU ARE HEREBY ORDERED TO: 1. Begin or maintain health insurance coverage on the child(ren). You may deduct any premium or costs from the wages or earnings of the OBLIGOR {name of person who was ordered to provide health insurance} _________________________________________. 2. If the OBLIGOR works for you, or if you have health insurance coverage available to OBLIGOR, you must give him or her a copy t ofhis order within 10 days after you receive it. 3. If no health insurance coverage is available to the OBLIGOR, complete and sign the DECLARATION OF NO HEALTH INSURANCE COVERAGE form and mail the declaration within 20 days to the attornor person requestingey the insurance coverage.DONE AND ORDERED at Brevard County, Florida, on the _____ day of ________________, 200___. ___________________________________ Circuit Judge Law 1024 rev. 8/2004 American LegalNet, Inc. www.USCourtForms.com>>>> 2Cc: Petitioner or their attorney (if represented) Respondent or their attorney (if represented)Name_____________________________ Name_______________________________ Address___________________________ Address_____________________________ _________________________________ ____________________________________ City State Zip City State ZipObligors Employer Name_____________________________ Address___________________________ __________________________________ City State Zip IF A NONLAWYER HELPED YOU FILL OUT THIS FORM TO GIVE TO THE JUDGE TO SIGN, THE NONLAWYER WHO HELPED YOU MUST FILL IN THE BLANKS BELOW: [
fill in all blanks] I, {full legal name and trade name of nonlawyer} ____________________________________, a nonlawyer, located at {street} ______________________________, {city} ______________________, {state} ______________, {phone}_______________, helped {Petitioners name} __________________, ____________________________________, who [ one onlyone ] _____petitioner or _____ respondent,fill out this form. Law 1024 rev. 8/2004 American LegalNet, Inc. www.USCourtForms.com