FAM402 State ENG Rev 5/11www.mncourts.gov/formsPage 1 of 1NOTICE OF INTENT TO COLLECT UNREIMBURSED OR UNINSURED HEALTH CARE EXPENSES AND REQUEST FOR PAYMENTMinn. Stat. 247 518A.41, subd. 17To: Name of Non-Requesting Party: Street Address: City, State, Zip: Date Mailed to Non-Requesting Party:Request for Payment: Please pay me , which is your share of our jointchildren222s unreimbursed or uninsured health expenses that you are court-ordered to pay. I have enclosed an Affidavit of Health Care Expenses and Demand for Payment to explain this amount. You have 30 days from the date I mailed this notice to you (not the date you actually received this notice) to either: 225Pay the requested amount in full,225Agree to a payment schedule with me, or225Serve and file a motion requesting a court hearing to contest the amount due or to set acourt-ordered monthly payment amount. If you do not respond within 30 days of the date I mailed this notice to you, I may seek enforcement options, including: 225If the Child Support Agency is involved in our case, I may submit the amount requested tothem for collection. 225I may file a motion with the court asking that the requested amount be added to the amountof arrears you owe. Or, if there are no arrears, then asking the court to set a monthly payment schedule. I may also ask the court to enter a judgment against you for the requested amount. If you disagree with the amount requested, and we are unable to resolve the dispute, you can serve and file a Notice of Motion, Motion and Affidavit to Contest Request for Payment of Unreimbursed or Uninsured Health Care Expenses. You must serve and file the motion within 30-days of the date I mailed this Notice to you. The Motion form is available at www.mncourts.gov/forms. Dated: Signature Name: Address: City/State/Zip: Telephone: E-mail address: County and State where signed American LegalNet, Inc. www.FormsWorkFlow.com