IN THE DISTRICT COURT OF WYANDOTTE COUNTY, KANSAS  CIVIL COURT DEPARTMENT IN THE MATTER OF: _______________________________________ Petitioner CASE NO: _______________________ DIVISION NO: ____________ CHAPTER 60 and _______________________________________ Respondent MOTION FOR REIMBURSEMENT OF MEDICAL/DENTAL EXPENSES COMES NOW the (Petitioner/Respondent) and moves the Court to grant a Judgment against the (Petitioner/Respondent) for reimbursement of medical/dental expenses. a. Judgment to be granted in the amount of $_________________ against the (Petitioner/Respondent) for medical/dental expenses, to be paid through the Kansas Payment Center. b. Attached are copies of the medical/dental bills (which have been paid) with a cover page summary of the bills. c. Enclosed is a copy of the page(s) of the Divorce Decree/Property Settlement Agreement, which states that the (Petitioner/Respondent) shall be responsible for all or a portion of the medical/dental expenses. d. I have already requested payment of the above expenses from the (Petitioner/Respondent) but such request has been refused. NOTICE OF HEARING Please take notice that the above motion has been set for hearing before the Hearing Officer at the Wyandotte County Courthouse, 710 N. 7th Street, Kansas City, Kansas. (DATE)____________________________________________________________ (TIME)_________________________________________________(A.M./P.M.) (PLACE OF HEARING) DIVISION 18 – SECOND FLOOR CERTIFICATE OF MAILING (to be completed only if you choose service by U.S. Mail-Postage Pre-Paid at last known address) I hereby certify that a true and correct copy of the above and foregoing document was placed in the United States Mail, postage prepaid on this _____day of ____________________________, 20___, to the (Petitioner/Respondent/attorney of record) as follows: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________ Your Signature Pro Se Home Address_________________________ ____________________________________ Day time Phone #______________________ American LegalNet, Inc. www.FormsWorkFlow.com