Form CCFC184 – Addendum to Parenting Plan Part B Extraordinary Medical Expenses Mother: Case Information 1. Payment of Extraordinary Medical Costs to be included on Form 14 Case Number Father: County Exhibit Number Extraordinary medical costs are predictable and recurring, such as expenses for dental treatment, orthodontic treatment, asthma treatment and physical therapy. These specific extraordinary medical expenses are included on Line 6d of Form 14 and shall be paid as follows: Current Uncovered Extraordinary Medical Costs to be Paid by Father INCLUDED on Form 14 _________________________________________ _________________________________________ _________________________________________ Total Amount of Expense $_________ per month $_________ per month $_________ per month The total cost of these extraordinary child-rearing costs of the children is $___________ per month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must include this amount on Form 14 - Line 6e) Current Uncovered Extraordinary Medical Costs to be Paid by Mother INCLUDED on Form 14 _________________________________________ _________________________________________ _________________________________________ Total Amount of Expense $_________ per month $_________ per month $_________ per month The total cost of these extraordinary child-rearing costs of the children is $___________ per month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must include this amount on Form 14 - Line 6e) Parenting Plan Part B – Support of Children – Extraordinary Medical Expenses Form CCFC184-11/09 American LegalNet, Inc. www.FormsWorkFlow.com