CSD902 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 Notice of Motion and Motion To Modify Medical Support ONLYNOTICETo: Other Party: First Middle Last Street Address Apt. No. City State Zip CodePLEASE TAKE NOTICE that the undersigned will bring a motion before the Honorable (Name of Judge or Referee)on (Date of hearing)at (Time) o'clock (a.m./p.m.)at the (Name of building where hearing to be held)County Courthouse or GovernmentCenter located at (Street address where hearing to be held)in the city of (City where hearing to be held)Minnesota, (check the public calendar at the hearing locationfor the room number), and will ask the court to modify the current support order as requested in the following motion.MOTIONNOTE: This motion form can only be used if your current support order was created less than three (3) years ago. If your current order is from more than three (3) years ago or if medical American LegalNet, Inc. www.FormsWorkFlow.com CSD902 State ENG Rev 5/16www.mncourts.gov/formsPage 2 of 3 support was reserved in the current order, then you must use the Motion to Modify Child Support forms instead.I request that the court modify the support order dated (Date of current support order)by ordering the following (check all the apply): Requiring the other parent to provide medical and/or dental insurance coverage for the jointchildren due to a change in the availability of coverage or a change in eligibility for medical assistance. Requiring me to provide medical and/or dental insurance coverage for the joint childrendue to a change in the availability of coverage or a change in eligibility for medical assistance. Changing the amount the other parent pays towards the coverage I carry for the joint children due to a substantial change in the cost of coverage. Changing the amount I pay to the other parent who provides the coverage for the joint children due to a substantial change in the cost of coverage. Changing which party is ordered to provide medical and/or dental coverage because theparty ordered to provide coverage has not done so. Changing or awarding the tax dependency exemption for the joint children to the parentordered to carry medical and/or dental insurance coverage.NOTE: If you want the court to change the percentage share of the cost of coverage or the percentage share of the out of pocket medical expenses (for example - deductibles and co-pays) DO NOT use this form. Use the Motion to Modify Child Support Form packet instead. The facts upon which I base my request are set forth in the attached Affidavit in Support of Motion to Modify Medical Support Only.Notice of Rights to Other Parties: 267 You have a right to a hearing, if a hearing is not already scheduled. 267 You have the right to object or respond to the changes I am requesting. 267 If you decide to respond or object to this motion, a packet entitled Response to Motion to Modify Medical Support Only is available on the court website at www.mncourts.gov/forms under the 223Child Support224 Category or from court administration. 267 If you choose to respond, a written response or counter motion, along with your supporting documents, must be served upon all parties at least 10 days before any scheduled hearing. A counter motion is where you can raise new child support issues, in addition to responding to the issues in this motion. 267 You must file your written response or counter motion, and supporting documents at least 5 days before any scheduled hearing. 267 The court may, in its discretion, choose not to consider any documents you file with the court if they are not filed on time. American LegalNet, Inc. www.FormsWorkFlow.com CSD902 State ENG Rev 5/16www.mncourts.gov/formsPage 3 of 3SettlementThis matter may be settled without a court hearing if all parties, reach an agreement. To discuss a possible settlement, contact the following person at the phone number listed: (Name of person filing motion)at (Phone number of person filing motion)Note: Person to contact for settlement should be the party bringing the action or the attorney, if an attorney is representing the party in this matter. Acknowledgment by Party Making Motion a.I am not serving or filing this document for any improper purpose, such as to harass or tocause unnecessary delay or needless increase in the cost of litigation.b.The claims, defenses, and other legal contentions therein are warranted by existing law orby a nonfrivolous argument for the extension, modification, or reversal of existing law orthe establishment of new law.c.The allegations and other factual contentions have evidentiary support or, if specificallyso identified, are likely to have evidentiary support after a reasonable opportunity forfurther investigation or discovery.d.The denials of factual contentions are warranted on the evidence or, if specifically soidentified, are reasonably based on a lack of information or belief.e.The court may impose an appropriate sanction upon the attorneys, law firms, or partiesthat violate the above stated representations to the court, or are responsible for theviolation.f.I understand that the existing order remains in full force and effect and I must continue tocomply with that order until a new order is issued. Dated: Signature Name: Address: City/State/Zip: Telephone: E-mail address: Attorney for: American LegalNet, Inc. www.FormsWorkFlow.com