FAM404 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 3State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Plaintiff / Petitioner (first, middle, last)vs / and Defendant / Respondent (first, middle, last) In Re the Marriage of: IntervenorNotice of Motion, Motion and Affidavit to Collect Unreimbursed or Uninsured Health Care Expenses (Minn. Stat. 247518A.41, subd. 18)NoticeTO: Other Party: First Middle Last Street Address Apt. No. City State Zip Country Attorney's Office (fill in if the County Child Support Agency is involved in your case) Name of County providing child support servicesCounty Street Address City State ZipPLEASE TAKE NOTICE that the undersigned will bring a motion before the Honorable (Name of Judge, Referee, or Child Support Magistrate), on Date: Month, Day, Yearat (Time)at the (Name of building where hearing to be held)County Courthouseor Government Center 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 location for the room number).and will ask the court to issue an order as requested in the following motion. American LegalNet, Inc. www.FormsWorkFlow.com FAM404 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 3MotionI request that the Court: 1.Find that the amount the other parent owes me for the joint children's unreimbursed or uninsured health care expenses is2.Order that this amount be paid to me in full by date, OR order thatthis amount be subject to enforcement as arrears or paid according to a monthly paymentschedule.3.Order that a judgment be entered in my favor, against the other parent, in the amount of , if the court deems it appropriate.4.Order any other relief the court deems just.Notice of Rights to Other Party 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 my requests. 267 If you choose to respond, a written response must be served upon all parties and the county attorney (if the county child support agency is involved with our child support) at least 5 days before any scheduled hearing. If your written response includes new issues in addition to replying to issues raised in this Motion, your response must be served upon all parties at least 10 days before the scheduled hearing. NOTE: The MN Judicial Branch publishes a packet of forms called 223Motion to Contest Unreimbursed or Uninsured Medical Expenses224 that you can use to respond. Forms are available at www.mncourts.gov/forms. 267 You must file a copy of your written response and supporting documents with Court Administration at least 5 days before any scheduled hearing, or 10 days before the hearing if your response raises new issues. 267 The court may, in its discretion, choose not to consider any documents you file with the court after the deadline. SettlementThis matter may be settled without a court hearing if all parties, including the county attorney, reach an agreement. To discuss a possible settlement, contact: (Name of person to contact to discuss settlement) (Phone number of person to contact)AffidavitI state the following facts upon which I base my request: 1.OnI mailed to the other party the Notice of Intent to Collect HealthCare Expenses, the Affidavit of Health Care Expenses, and copies of bills, receipts and Explanations of Benefits from the insurance company.2.I have attached a copy of these documents to support this Affidavit. 3.The other party owes mefor unreimbursed or uninsured health care American LegalNet, Inc. www.FormsWorkFlow.com FAM404 State ENG Rev 7/15www.mncourts.gov/formsPage 3 of 3 expenses for the joint children incurred between:(date of earliest service) and(date of latest service).4.I asked the other party to pay me in full, or to contact me about a payment plan, within 30 days. The thirty days were up on5.Since I sent the Affidavit of Health Care Expenses,the other party has paid me toward the reimbursment amount. 6.The other party still owes me a total of7.Other: Acknowledgment by Party Making Motion:a.I am not serving or filing this document for any improper purpose, such as to harass orto cause unnecessary delay or needless increase in the cost of litigation.b.The claims, defenses, and other legal contentions therein are warranted by existing lawor by a nonfrivolous argument for the extension, modification, or reversal of existinglaw or the 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. 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