CSX2303 State ENG Rev 5/16www.mncourts.gov/formsPage 1 of 3State of Minnesota District Court County of:Select County Judicial District: Court File Number: Case Type: Petitioner (first, middle, last) and Respondent (first, middle, last) In Re the Marriage of: Intervenor Affidavit in Support of Motion to Modify Medical Support ONLYI state that the following information is true and correct to the best of my knowledge. 1. My name is .2. In this case, medical support is for: Child's Name Date of Birth Is there court-ordered parenting time? YES NO YES NO YES NO YES NO YES NO(Attach a page if more space is needed)If you and the other parent have any other minor children together who are not a part of this court case, write the children's names and dates of birth here: 3. The current order that states which party is to provide medical or dental insurance and divides the costs of insurance, was issued by the court inCounty and is dated. American LegalNet, Inc. www.FormsWorkFlow.com CSX2303 State ENG Rev 5/16www.mncourts.gov/formsPage 2 of 3NOTE: If the order is more than three (3) years old, or if the order reserves the issue of medical support, DO NOT USE THIS FORM. Use the Motion to Modify Child Support Form packet instead.4. I am ONLY asking the court to modify the current medical support. I will provide proof to support my requests below. I request a change only in the current medical support part of the order because of: (check all that apply) Change in the availability of medical and/or dental insurance coverage for the joint children. The parent currently ordered to provide coverage is me other party. Substantial change in the cost of medical and/or dental insurance coverage for the joint children. Change in eligibility for Medical Assistance for the children me other party. Parent ordered to provide coverage has not provided coverage for the joint children. Tax dependency exemption is not ordered to be with the parent ordered to carry coverage. Tax dependency exemption was not addressed in the current order and the noncustodial parent is ordered to carry the coverage.NOTE: This form CANNOT be used to change the percentage share of the cost of coverage or the percentage share of out of pocket medical and dental expenses (for example deductibles and co-pays). Use the Motion to Modify Child Support Form packet instead.5. I make the following other comments in support of my request for a change in Medical Support in my current order. (Explain the items you checked at #4. For example, why has the availability of medical and/or dental insurance changed? How much has the cost changed? Attach documents or bills that help to prove what you are saying.) If you need more space, attach a sheet of paper . 6. The children currently have health care coverage as follows (this may be different than what is currently ordered): MinnesotaCare Medical Assistance No coverage I provide coverage Other parent provides coverage Other a) Is the person actually providing the coverage, as stated above, the person ordered to provide the coverage? Yes Nob) Health care coverage is available for the children through my work or union: Yes NoIf yes, answer the following:i. Cost of monthly health care coverage for self: American LegalNet, Inc. www.FormsWorkFlow.com CSX2303 State ENG Rev 5/16www.mncourts.gov/formsPage 3 of 3ii.Cost of monthly health care coverage for dependents: iii.Cost of monthly dental insurance for self (if separate coverage from health care coverage):iv.Cost of monthly dental insurance for dependents (if separate coverage from health care coverage):c)If coverage is not available through your work, have you checked on the cost of buyingprivate insurance to cover the health needs of the children? Yes NoIf yes, what is the cost? per month.7.I receive (check only if it applies): MinnesotaCare Medical Assistance General Assistance SSI8.To the best of my knowledge, the other parent receives: MinnesotaCare Medical Assistance General Assistance SSII declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com