Original - Court 2nd copy - Requesting party Approved, SCAO 1st copy - Obligor 3rd copy - FOC file STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT COMPLAINT FOR ENFORCEMENT OF COUNTY HEALTH CARE EXPENSE PAYMENT Friend of the Court address Telephone no.Plaintiff Defendant v TO: Obligors name and address Notice to Obligor: Under MCL 552.611a, the friend of the court has been asked to enforce the health care expenses described below. Unless you filea written objection with the friend of the court within 21 days of the date provided in MCL 552.611, the expenses will be added to yoursupport account as a health care support arrearage and enforced. If you timely file a written objection in the manner required, a hearingwill be set to resolve the health care complaint. I certify that on this date I mailed a copy of this complaint to the obligor by ordinary mail to the obligors last known address.Date Friend of the court/Authorized representative Requesting Partys Statement: I request the friend of the court to enforce health care expenses. Attached is the request for Health Care Expense Payment (includingall supporting documents) given to the obligor. I declare that: 1. I requested payment within 28 days of the date notified of the balance due after insurance payments. 2. This request is for expenses that are more than the minimum amount my order requires for enforcement. 3. This complaint is within 6 months after the date of the insurers final denial of coverage for the expense. within 1 year of the date the expense was incurred. within 6 months after the obligors default of an agreement to repay (copy of agreement attached). 4. As of this date, the expense information in the attached Request for Health Care Expense Payment is true except as follows: Since the date I mailed the Request for Health Care Expense Payment to the obligor, the obligor paid $____________________ for ____________________________________________________ and ____________________________________________ . Name(s) of child(ren) Name(s) of medical provider(s) I declare that the above statements are true to the best of my information, knowledge, and belief. Date Signature FOC 13a (6/03) COMPLAINT FOR ENFORCEMENT OF HEALTH CARE EXPENSE PAYMENT MCL 552.531, MCL 552.602