Petition For Dissolution Of Marriage Page 11
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15AGREEMENT: Health insurance for the child(ren) will be purchased by
father at a monthly cost to father of $
*
mother at a monthly cost to mother of $
*
through the above person’s
employer
union
whose name and address are
The cost will be divided between the parties
equally
Explain reason for unequal division:
*List only the cost to insure the children involved in this case. If there is no extra cost
to the parent to include the children in the parent’s insurance coverage, none of the
cost can be allocated to the children. See Civil Rule 90.3(d) for further explanation.
b. Health Care Expenses Not Covered By Insurance (including medical, dental, vision and
mental health counseling expenses).
We agree that the cost of the children’s reasonable health care expenses not covered by
insurance will be paid as follows (unless the expenses are over $5,000 in a calendar
year):
Father will pay half and mother will pay half.
Father will pay
and mother will pay
.
Explain reason for not sharing these uninsured expenses equally:
If the uncovered expenses are over $5,000 in a calendar year, the expenses must be
allocated based on the parties’ relative financial circumstances when the expense
occurs.
We agree that each of us will reimburse the other for our share of uncovered health care
expenses within 30 days after we are given the bill, proof of payment and, if applicable,
a health insurance statement showing what part of the cost is uncovered. We understand
that the bills and other materials must be sent to the other parent for reimbursement
within a reasonable time.
5. Monthly Child Support Payment (after adding or deducting health insurance costs).
a. Monthly Child Support Payment from paragraph 3 above
0
(on page 10)
$
b. If obligor is buying health insurance for the child(ren), subtract
50% (or
%) of the monthly insurance payment.
– $
(The “obligor” is the parent paying child support.)
c. If obligee is buying health insurance for the child(ren), add
50% (or
%) of the monthly insurance payment.
+ $
(The “obligee” is the parent receiving child support.)
0
d.
Net Monthly Child Support Payment
$
Husband’s Signature
Wife’s Signature
Page 11 of 15
DR-105 (4/09)(cs)
AS 25.24.200-.260
PETITION FOR DISSOLUTION OF MARRIAGE (WITH CHILDREN)
Civil Rule 90.1(a), f(2)(A)(B), (i)(1)
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