Form Nhjb-2066-Fp - Judicial Branch - State Of New Hampshire Page 3
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6Case Name:
Case Number:
UNIFORM SUPPORT ORDER
13
.
The medical support reasonable cost obligation is adjusted from the presumptive
A
amount because of the following special circumstances (Enter applicable circumstances
below. See Standing Order 6):
14. Private health insurance coverage
is not available
is available to the OBLIGEE in an
amount equal to or less than the amount of the medical support reasonable cost
obligation ordered in paragraph 13.
15.
Private health insurance coverage available to the OBLIGEE is not accessible to the
child(ren).
PRIVATE HEALTH INSURANCE COVERAGE (Paragraph 16
and/or 16
must be completed):
A
B
16
.
Obligor
Obligee is ordered to provide private health insurance coverage for the
A
child(ren) effective
16
.
Obligor
Obligee is/are not ordered to provide private health insurance coverage at this
B
time but is/are ordered to immediately obtain private health insurance coverage when it
becomes accessible and available at an amount equal to or less than the ordered medical
support reasonable cost obligation.
UNINSURED MEDICAL EXPENSES
17. Uninsured medical expenses shall be paid in the following percentage amounts:
Obligor
% Obligee
% Other:
18. Public assistance (TANF) or medical assistance (Medicaid) is or was provided for the children.
Copies of pleadings related to medical coverage and child support were mailed to the Division
of Child Support Services, Child Support Legal, 129 Pleasant Street, Concord, NH 03301.
19.
Obligor
Obligee is adjudicated the father of the minor child(ren) named above. The clerk
of the city(ies) of
shall enter the name of the father on
the birth certificate(s) of the child(ren). The father’s date of birth is
and
his state of birth is
.
20. The State of
has provided public assistance for the benefit
of the minor child(ren) between
and
for
weeks. Obligor is indebted for the assistance in the total amount of $
21. Variation to standing order (specify paragraph #), additional agreement or order of the Court:
Obligor
Obligee
Staff Attorney
Division of Child Support Services
Obligor’s Attorney/Witness
Obligee’s Attorney/Witness
Date
Date
Date
Top of 1st Page
NHJB-2066-FP (07/14/2014)
Page 3 of 6
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