NOTIFICATION TO CLERK OF THE COURT To: Clerk of the Circuit Court 22nd Judicial Circuit, McHenry County 2200 N. Seminary Avenue Woodstock, Illinois 60098 (Also send form to the Illinois Department of Healthcare & Family Services in cases where recipient is receiving child and support services under Article X of the Illinois Public Aid Code) Re: Case Name:_____________________________________________________________________ _______________________________________________________________________________ Case Number:___________________________________________________________________ Name of Support Obligor:__________________________________________________________ EMPLOYER CHANGE Name and Address of New Employer: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ INSURANCE CHANGE In the event of a change of employment or change in insurance carriers, state whether the obligor has access to health insurance coverage through the new employer or other group coverage: _____________________________________________________________________________________ If so, state the policy name, policy number, and the names of persons covered under the policy: Policy Name:__________________________________________________________________________ Policy Number:________________________________________________________________________ Persons Covered Under Policy:____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ADDRESS/PHONE CHANGE Provide any new residential or mailing address or telephone number: Address:______________________________________________________________________________ _____________________________________________________________________________________ Telephone Number:_____________________________________________________________________ ___________________________________________ ___________ Signature CS-NOT1: Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com Date