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National Medical Support Notice Part A - Texas
| National Medical Support Notice Part A Form. This is a Texas form and can be used in Child Support Attorney General Statewide . |
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NATIONAL MEDICAL SUPPORT NOTICE - PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998. Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form, the Custodial Parent may also be the employee when the State opts to enforce against the Custodial Parent. Issuing Agency: ________________________________ Issuing Agency Address: ________________________ _____________________________________________ Notice Date: __________________________________ CSE Agency Case Identifier: ______________________ Telephone Number:______________________________ FAX Number:___________________________________ Court or Administrative Authority: __________________ Order Date: ___________________________________ Order Identifier: ________________________________ Document Tracking Identifier: _____________________ Employer web site: _____________________________ See NMSN Instructions: www.acf.hhs.gov/programs/cse/forms/ _________________________________________ Employer/Withholder's Federal EIN Number _________________________________________ Employer/Withholder's Name _________________________________________ _________________________________________ _________________________________________ Employer / Withholder's Address _________________________________________ Custodial Parent's Name (Last, First, MI) _________________________________________ _________________________________________ _________________________________________ Custodial Parent's Mailing Address _________________________________________ _________________________________________ _________________________________________ Child(ren)'s Mailing Address (if different from Custodial Parent's) _________________________________________ Name and Telephone of a Representative of the Child(ren) Child(ren)'s Name(s Gender DOB SSN ____________________ _____ ________ _____ ____________________ _____ ________ _____ ____________________ _____ ________ _____ RE: ____________________________________________ Employee's Name (Last, First, MI) ____________________________________________ Employee's Social Security Number ____________________________________________ ____________________________________________ ____________________________________________ Employee's Mailing Address ____________________________________________ Substituted Official/Agency Name ____________________________________________ ____________________________________________ ____________________________________________ Substituted Official/Agency Address (Required if Custodial Parent's mailing address is left blank) ____________________________________________ ____________________________________________ ____________________________________________ Mailing Address of a Representative of the Child(ren) Child(ren)'s Name(s) ____________________ ____________________ ____________________ Gender DOB _____ ________ _____ ________ _____ ________ SSN ________ ________ ________ The order requires the child(ren) to be enrolled in all health coverages available; or only the following coverage(s): Medical; Dental; Vision; Prescription dru Mental health; Other specify):________________________ g; THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB control number: 0970-0222 Expiration Date: 03/31/2014. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com LIMITATIONS ON WITHHOLDING The total amount withheld for both cash and medical support cannot exceed ____________% of the employee's aggregate disposable weekly earnings. The employer may not withhold more under this National Medical Support Notice than the lesser of: 1. The amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C., section 1673(b)); 2. The amounts allowed by the State of the employee's principal place of employment; or 3. The amounts allowed for health insurance premiums by the child support order, as indicated here:_________________________________. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as State, Federal, local taxes; Social Security taxes; and Medicare taxes. As required under section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholding. PRIORITY OF WITHHOLDING If withholding is required for employee contributions to one or more plans under this notice and for a support obligation under a separate notice and available funds are insufficient for withholding for both cash and medical support contributions, the employer must withhold amounts for purposes of cash support and medical support contributions in accordance with the law, if any, of the State of the employee's principal place of employment requiring prioritization between cash and medical support, as described here: __________________________________________________. As required under section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholdings. Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYER RESPONSE If 1, 2, 3, 4 or 5 below applies, check the appropriate box and return this Part A to the Issuing Agency within 20 business days after the date of the Notice, or sooner if reasonable. NO OTHER ACTION IS NECESSARY. If 1 through 5 does not apply, complete item 7 and forward Part B to the approp
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