Addendum To Stipulation Of Settlement-Agreement Re Compliance With Domestic Relations Law 255(c)
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Addendum To Stipulation Of Settlement-Agreement Re Compliance With Domestic Relations Law 255(c) Form. This is a New York form and can be use in Supreme Court Statewide.
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ADDENDUM TO STIPULATION OF SETTLEMENT/AGREEMENT
RE: COMPLIANCE WITH DOMESTIC RELATIONS LAW 255(2)
___________________________ Vs
___________________________
Index #:_________
Each party is aware that he or she will no longer be covered by the
other party’s health insurance plan and that each party shall be responsible for his or her own
health insurance coverage, and may be entitled to purchase health insurance on his or her own
through a COBRA option, if available.
Dated:
, 20_____
SS:
___________________________________
Plaintiff’s Signature
___________________________________
Print Name
STATE OF __________________, COUNTY OF _______________
On this ______ day of ____________ 20____ , before me; the undersigned,
personally appeared ___________________, personally known to me or proved to me on the basis
of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature
on the instrument, the individual, or the person upon behalf of which the individual acted, executed
the instrument.
________________________
NOTARY PUBLIC
Dated:
, 20_____
SS:
____________________________________
Defendant’s Signature
____________________________________
Print Name
STATE OF __________________, COUNTY OF _______________
On this ______ day of ____________ 20____ , before me; the undersigned,
personally appeared ___________________, personally known to me or proved to me on the basis
of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature
on the instrument, the individual, or the person upon behalf of which the individual acted, executed
the instrument.
________________________
NOTARY PUBLIC
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