FAM403 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 2AFFIDAVIT OF HEALTH CARE EXPENSES and DEMAND FOR PAYMENTMinn. Stat. 247 518A41, subd. 17 1. My full name is 2. I am party to Court Case No:in County,Minnesota and this case includes a child support order. 3. The other parent, is required by Court order(s) to pay % of our joint children's unreimbursed or uninsured health care expenses, and I am required to pay% 4. To the best of my knowledge, information, and belief the following is a list of the joint children222s unreimbursed or uninsured health care expenses for which the other parent has not paid his/her full share: Name of Joint Child Who Received the Care Date Care Was Provided (Limited to costs within the past 2 years) Name of Provider (doctor, dentist, clinic, hospital) Description of Medical/Dental Care Received Amount Not Covered by Insurance (Out of pocket expense) If you need more space, add additional sheets of paper. Total Amount: $0.00 American LegalNet, Inc. www.FormsWorkFlow.com FAM403 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 25.The total amount of unreimbursed or uninsured health care expenses from the period through is 6.My share of this expense is , and the other parent's share is 7.The other parent has paid metowards these expenses. 8.Therefore, I am asking that within 30 days, the other parent pay meforhis/ her portion of the unreimbursed or uninsured health care expenses or agree to a paymentschedule with me until the requested amount is paid in full.9.The attached documents provide proof and details of the medical or dental expenses, and areincorporated into this Affidavit. Signature I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116.Dated: Name: Address: City/State/Zip: Telephone: E-mail address: County and State where signed American LegalNet, Inc. www.FormsWorkFlow.com