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Health Insurance Status Change Form 3F012 - Texas

Health Insurance Status Change Form Form. This is a Texas form and can be used in Child Support Attorney General Statewide .
 Fillable pdf Last Modified 4/3/2008
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Office of the Attorney General MEDICAL SUPPORT UNIT P.O. BOX 1328 AUSTIN, TEXAS 78767-1328 Toll-Free (800) 522-2421 FAX (512) 407-9249 Bar Code Area (w/ NCP SSN) GREG ABBOTT Attorney General Date: Custodial Parent: Non-Custodial Parent: Attorney General Case #: Cause #: HEALTH INSURANCE STATUS CHANGE FORM Employers are required to notify the Office of the Attorney General of a change of status of an employee [Texas Family Code, 154.187 and 158.211. Please keep this form for use as needed. If there is a change in the employee's health insurance or employment status, please complete this form and return it to: Medical Support Unit P.O. Box 1328 Austin, TX 78767-1328 If you have any questions, please call (800) 522-2421. For information about providing this information via the Internet, please visit https://www.mscompliance.com/texas/. Obligor: Social Security Number: Date of occurrence: ____________________________________Attorney General Case #. This is to advise of a change in employment status between the above obligor and this employer. [ ] The obligor is no longer employed by this employer; income withholding will stop on _______________________ (Notification of withholding interruption must be made within 7 days.) The obligor's last know home address: _______________________________________ _______________________________________ Telephone Number: _______________________ [ ] Health insurance coverage has lapsed. Notification of insurance interruption m ust be within 15 days of occurrence. If the obligor is eligible for health insurance conversion privileges (COBRA), please enclose information. The obligor's new employer name and address if known: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________ Signature of Person Completing Form _______________________________ Date Form Completed ________________________________________ Position / Title ________________________________ (Area Code) Telephone Number _______________________________________ Internet/Web Address September 2005 Form 3F012 American LegalNet, Inc. www.USCourtForms.com
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