ODHS 4040 (1/98) NOTICE TO EMPLOYER TO ENROLL EMPLOYEE IN HEALTH INSURANCE PLAN Date of Issuance: Issued by: Issued to: (Employer) MAHONING COUNTY DOMESTIC RELATIONS COURT MAHONING COUNTY COURTHOUSE 120 MARKET STREET YOUNGSTOWN, OHIO 44503 ____________________________________ ____________________________________ ____________________________________ ____________________________________ CSEA Identification Number:_____________ RE: (Obligor) _____________________________________ CASE NO.:____________________ SSN:________________________________ GENERAL PURPOSE OF THIS NOTICE A court or administrative order requires that your employee enroll the children named in the Child Support Order in your company's health insurance plan in accordance with the Revised Code Sections 3111.241 or 3113.217. These statutory sections mandate that the specific withholding and deduction requirements will be communicated by this notice. The notice is final and enforceable by the court. This notice is transmitted by regular mail from the Domestic Relations Court, the Juvenile Court or the Child Support Enforcement Agency of the jurisdictional county. A copy is provided to your employee. This notice applies to all successor employers who are required to comply with all orders herein. Enrollments to begin no later than the first payment that occurs after 14 work days following the date of this notice. THIS NOTICE REPLACES ANY PRIOR COURT ORDERS OR ADMINISTRATIVE NOTICES TO PROVIDE HEALTH INSURANCE UNDER THIS IDENTIFICATION NUMBER. The withholding in accordance with the notice and under the provisions of this section has priority over any other legal process under the law of this State. DHS 4040 (1/98) American LegalNet, Inc. www.USCourtForms.com ODHS 4040 (1/98) PAGE 2 NOTICE TO EMPLOYER TO ENROLL EMPLOYEE IN HEALTH INSURANCE PLAN REQUIREMENTS FOR EMPLOYER 1. The new employer must take whatever action is necessary to make application to enroll the employee required to obtain health insurance coverage in any available group health insurance or health care policy, contract, or plan with coverage for the children; 2. The new employer must submit a copy of the child support order requiring the obligor or obligee to obtain health care insurance for the children to the insurer at the time that the employer makes application to enroll the children in the health insurance or health care policy, contract, or plan; 3. If the application is accepted, the new employer must deduct from the wages or other income of the obligor or obligee required to obtain the health insurance coverage the cost of the coverage for the children. Penalties may be applied if you fail to comply. The provisions of the notice are final and enforceable by a court and are incorporated into the child support order unless the obligor or obligee required to obtain health insurance coverage, within ten days after the date on which the notice is sent, files a written request with the agency requesting modification of the child support order pursuant to Section 3113.216 of the Revised Code. If the income provider fails to comply with this notice, the county child support enforcement agency will bring an action requesting the court to issue an order requiring compliance pursuant to Ohio Revised Code Section 3111.241 or 3113.217. The income provider may be found guilty of contempt of court. The child(ren) who is/are the subject of the health order is/are as follows: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ SSN:___________________ SSN:___________________ SSN:___________________ SSN:___________________ SSN:___________________ SSN:___________________ SSN:___________________ DOB:_____________ DOB:_____________ DOB:_____________ DOB:_____________ DOB:_____________ DOB:_____________ DOB:_____________ QUESTIONS? Questions regarding this notice can be directed to: Mahoning County Child Support Enforcement Agency, 112 W. Commerce Street, P. O. Box 119, Youngstown, Ohio 44501-0119, Telephone: (330) 740-2073. American LegalNet, Inc. www.USCourtForms.com