Affidavit Of Health Care Expenses

AFFIDAVIT OF HEALTH CARE EXPENSES __________________________________ Name _____________________________ Case Number I ______________________________________swear that health care expenses (print your name here) incurred on behalf of the minor child(ren) have exceeded $289.00 or $345.00 per child, which is the annual amount designated as "ordinary health care expenses". I have presented copies of these expenses to the other party on this case. I swear under penalties of perjury that this information is true, accurate, and complete to the best of my information, knowledge and belief. _______________ Date ____________________________________ Signature Please use the table below to list the current year health care expenses up to the first $289 or $345 per child: Child Receiving service Health care provider Date of Service Type of Service Cost of Service Amount paid by insurance Out-of-pocket cost Grand total: $____________ American LegalNet, Inc. www.FormsWorkFlow.com