CSD601 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Petitioner (first, middle, last)and Respondent (first, middle, last) Intervenor In Re the Marriage of:Notice to Obligor of Medical Support Enforcement To:, ObligorYou are hereby notified pursuant to Minn. Stat. 247518A.41, that thirty (30) days have passed since entry of the court order dated. You have failed to provide writtenproof that the required health and dental insurance has been obtained, or that application for insurability has been made. If, after fifteen (15) days from the date of this notice, written proof that the insurance coverage exists is not received at the address listed below, a copy of the court order for insurance coverage will be forwarded to your employer or union. This order is binding on your employer or union. Upon receipt of the order, your employer or union will enroll the minor children named in the order as beneficiaries in an insurance plan and withhold any required premium from your income or wages. If more than one plan is offered by your employer or union, the children will be enrolled in the least costly plan otherwise available to you that is comparable to a number two qualified plan as defined by Minn. Stat. 247 62E.06, subd. 2 (2006). The children will remain eligible for insurance coverage until emancipated or until further order of the court. If dependent health and dental insurance is available for the benefit of your (ex-) spouse at no additional cost, the employer or union will also enroll that person. If you fail to maintain the health care coverage as ordered, you will be liable to the obligee for any medical or dental expenses incurred from the date of the court order. Proof of American LegalNet, Inc. www.FormsWorkFlow.com CSD601 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 2failure to maintain insurance constitutes a showing of increased need by the obligee pursuant to Minn. Stat. 247 518A.39 and provides a basis for a modification of your child support order. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: Attorney for: American LegalNet, Inc. www.FormsWorkFlow.com