COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. INSURANCE PREMIUM AND CHILD CARE ADJUSTMENT : Calendar No. WORKSHEET INSURANCE ADJUSTMENT Plaintiff(s) -against- : JUDICIAL SUBPOENA : Use this section of the worksheet to calculate how the children's medical insurance premium expenses change the amount the obligor pays to the obligee. : If the OBLIGOR parent is ordered to maintain medical insurance for the : children complete this section. Defendant(s) A. Enter the amount of the children's portion of the medical insurance premium : . . . . . . . . . . .actually.paid. by the.obligator.. . . . . . . . . . . . . . . . . . . . . . . ..... .. .... ...... $ $ B. Multiply Line A. by .50 to obtain the obligee's share of the premium. C. Subtract the amount in NEW YORK THE PEOPLE OF THE STATE OFLine B. from the base child support award to obtain TO the amount the obligor pays to the obligee for the months the premium is actually paid. Enter the result here. $ If the OBLIGEE parent is ordered to maintain medical insurance for the children complete this section. GREETINGS: D. Enter the amount of the children's portion of the medical insurance premium actually paid by the obligee. $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable Multiply Line D. by .50 to obtain the obligor's share of the premium. at the Court E. $ located at County of F. Add the amount in Line E. to the base child support award to obtain the in room , on the day of , 20 , at o'clock in the noon, and at any recessed amount the obligor pays to the obligee for the months the premium is actually or adjourned paid. to testify and give evidence as a witness in this action on the part $ the date, of No credit or offset is allowed unless the premium is actually paid. If the premium is not paid, the obligor must pay the amount of the base child support award. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a CHILD CARE ADJUSTMENT result of your failure to comply. Use this section of the worksheet to calculate how the children's child care expenses change Witness, Honorable the amount the obligor pays to the obligee. Court in County, day of , one of the Justices of the , 20 G. Enter the average amount of monthly child care expense actually paid by the obligee. $ H. Multiply Line G. by .50 to obtain the obligor's share of the child care sign above and type name below) (Attorney must expense. Enter the result here. Complete box I, J, or K below. $ I. If neither parent is maintaining insurance, add the amount in Line H. tot he base child support award to obtain the amount the obligor pays to the obligee Attorney(s) for for the months the child care expense is incurred. Enter the result here. $ J. If the obligor is maintaining insurance, add the amount in Line H. to the amount in Line C. to obtain the amount the obligor pays to the obligee for the months the child care expense is incurred. Enter the result here. $ K. If the obligee is maintaining insurance, add the amount in Line H. to the amount in Line F. to obtain the amount the obligor pays to the obligee for the months the child care expense is incurred. Enter the result here. $ Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 10/94 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. INSTRUCTIONS FOR THE INSURANCE PREMIUM AND CHILD CARE ADJUSTMENT : Calendar No. WORKSHEET Line A. Line B. : Plaintiff(s) Enter the children's portion of the medical insurance premium JUDICIAL SUBPOENA actually paid by the obligator. Obtain this figure by dividing the premium amount actually paid by the obligor by the number of -against: persons covered by the policy and then multiplying that number by the number of children in this case covered by the policy. : Complete the calculation as directed. : Defendant(s) Line C. Complete the calculation as directed. The base child support award is found on line 7 of the sole : ...................................................... custody worksheet, line 10 of the split custody worksheet and line 11 on the joint custody worksheet. Line D. Enter THE STATE OF NEW YORK THE PEOPLE OFthe children's portion of the medical insurance premium actually paid by the obligee. Obtain this figure by dividing the premium amount actually paid by the obligee by the number of persons covered by the policy and then multiplying that number by the number of children in this TO case covered by the policy. Line E. Complete the calculation as directed. GREETINGS: Line F. Complete the calculation as directed. The base child support award is found on line 7 of the sole WE COMMAND YOU, that of the split custody worksheet and line 11 on the joint custody attend before custody worksheet, line 10 all business and excuses being laid aside, you and each of you , the Honorable at the Court worksheet. located at County of inLine G. Enter the average amountof monthly child care expense actually paid by the obligee for the any recessed room , on the day of , 20 , at o'clock in the noon, and at or adjourned date, toin this case. give evidence as a witness in this action on the part of the children testify and Line H. Complete the calculation as directed. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Line L Complete the calculation as directed. The base child support award is found on line 7 of the sole the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a custody worksheet, line 10 of the split custody worksheet and line 11 of the joint custody result of your failure to comply. worksheet. Line J. Witness, Honorable Complete the calculation as directed. Court in County, day of Line K. Complete the calculation as directed. , one of the Justices of the , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com