Form Fl-476 - Request And Notice Of Hearing Regarding Health Insurance Assignment
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2FL-478
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
TELEPHONE NO.:
FAX NO. (Optional):
end of the form when finished.
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
REQUEST AND NOTICE OF HEARING REGARDING
HEALTH INSURANCE ASSIGNMENT
NOTICE: If you object to the Application and Order for Health Insurance Coverage (form FL-470) or National Medical
Support Notice (form OMB-0970-0222), complete and file this form with the court clerk to request a hearing. This form may
not be used to modify your current child support amount. (See "Information Sheet on Changing a Child Support Order" on
page 2 of form FL-192.)
1. A hearing on this application will be held as follows (see instructions for getting a hearing date on form FL-478-INFO):
a.
Date:
Time:
Dept.:
Div.:
Room:
b. The address of the court is
same as above
other (specify):
2.
I request that service of the Application and Order for Health Insurance Coverage (form FL-470) or National Medical Support
Notice (form OMB-0970-0222) be quashed (set aside) because:
a.
I am not the obligor named in the Application and Order for Health Insurance Coverage or National Medical Support
Notice.
Health insurance coverage is not available at a reasonable cost.
b.
The health insurance premium plus the monthly payment in any earnings assignment order are more than half of
c.
my total net income each month from all sources.
The following children (name):
are emancipated.
d.
I was not notified at least 15 days before the date of filing of the application that a health insurance coverage
e.
assignment was being sought.
No order to maintain health insurance has been issued.
f.
Health insurance coverage is or will be provided for the children, but not through a parent's job-related coverage
g.
(explain):
The employer's choice of coverage is inappropriate (explain):
h.
i.
Other (specify):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF PERSON REQUESTING HEARING)
(SIGNATURE OF PERSON REQUESTING HEARING)
Page 1 of 2
Form Adopted for Mandatory Use
REQUEST AND NOTICE OF HEARING REGARDING
Family Code, §§ 3761, 3765, and 3773
Judicial Council of California
HEALTH INSURANCE ASSIGNMENT
FL-478 [New January 1, 2007]
(Family Law—Governmental—UIFSA)
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