Complaint And Notice For Health-Care Expense Payment
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1
2
3Original - Friend of the court
1st copy - Obligor
2nd copy - Requesting party
STATE OF MICHIGAN
CASE NO.
th
7
JUDICIAL CIRCUIT
COMPLAINT AND NOTICE FOR
GENESEE COUNTY
HEALTH-CARE EXPENSE PAYMENT
Plaintiff
Defendant
v
TO:
COMPLAINT
I request the friend of the court to enforce health-care expenses. Attached is the request for health-care expense
payment (including all supporting documents) given to the obligor.
I declare that:
1. I requested payment within 28 days of the date notified of the balance due after insurance payments.
2. This request is for
expenses that are more than the annual ordinary medical amount that can be collected as specified
in the support order.
health-care expenses that have been incurred by the payer of support.
3. This complaint is
within six months after the date of the insurer's final denial of coverage for the expense.
within one year of the date the expense was incurred.
within six months after the obligor's default of an agreement to repay (copy of agreement attached).
4. As of this date, the expense information in the attached request for health-care expense payment is true
except as follows: Since the date I mailed the request for health-care expense payment to the obligor, the
obligor paid
$
for
_____________and
____________.
Name(s) of Child(ren)
Name(s) of Medical Providers
Date
Signature
COMPLAINT FOR HEALTH-CARE EXPENSE PAYMENT
FOC 13a (3/09)
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