Motion And Affidavit Requesting Payment For Childrens Health Care Expenses {DR-352}

Person Filing Motion: Name: Mailing Address: Attorney for Daytime Telephone No. Pro Se (not represented by an attorney) TYPE OR HAND PRINT NEATLY, USING BLACK INK ONLY List court location, names of parties and case number exactly as shown on child support order. IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) 1. Parent Information. CASE NO. MOTION & AFFIDAVIT REQUESTING PAYMENT FOR CHILDREN'S HEALTH CARE EXPENSES NOTE: If for any reason you do not want the other parent to know your current address, you need not provide that information. However, you must provide a mailing address that will allow the court and other parent to mail you required documents. That address may be in care of another person as long as you will receive all papers sent to you. Parent A: Full name: Mailing address: Daytime phone number: Parent B: Full name: Mailing address: Daytime phone number: 2. Court's Order Concerning Health Care Expenses Not Covered By Insurance. Attached is a copy of my most recent child support order, signed on . Date of Birth: Date of Birth: Under this order, the child(ren)'s health care expenses not covered by insurance are to be paid as follows, unless the expenses exceed $5,000 in a calendar year: Parent A must pay Parent B must pay half half of the expenses, and of the expenses. This support order does not describe how the child(ren)'s uninsured health care expenses are to be split between the parents. I request that the court order the other parent to pay half of the expenses I have paid. Page 1 of 3 Civil Rules 77, 90.3(d)(2) & (f)(5) DR-352 (3/16)(cs) American LegalNet, Inc. MOTION & AFFIDAVIT REQUESTING PAYMENT FOR CHILDREN'S HEALTH CARE EXPENSES www.FormsWorkFlow.com 3. Statement of Health Care Expenses (form DR-353), and have not been paid by insurance or by the other parent for the amounts shown in the chart. Request for Payment Sent to Other Parent. I wrote to the other parent on the following date(s) to request payment for that parent's share of the costs: I included with my request a copy of each health care provider's bill, proof of the amount I paid, and any information I had about the amount paid by insurance companies. It has been more than 30 days since I wrote to the other parent, and the other parent has not paid me. Payments Made. I have paid the health care expenses listed in the attached 4. 5. Request for Court Order. Because the amounts shown on the attached Statement(s) are past due, I ask the court to order to pay the total amount due. I have attached a proposed order. Additional Requests or Information Related to Health Care Expenses. 6. 7. Required Attachments. Each of the items listed below MUST be attached to this motion. Check each box to show that you have completed and attached the item. Copy of your most recent child support order Statement of Health Care Expenses (form DR-353) with the following: Copy of each health care provider's bill Copy of each Explanation of Benefits (EOB) from an insurance company EOBs not attached because: Proof of any amount you paid the health care provider Copy of each request for payment you sent the other parent Proposed order for the court to sign (form DR-355) Page 2 of 3 Civil Rules 77, 90.3(d)(2) & (f)(5) DR-352 (3/16)(cs) American LegalNet, Inc. MOTION & AFFIDAVIT REQUESTING PAYMENT FOR CHILDREN'S HEALTH CARE EXPENSES www.FormsWorkFlow.com OATH OR AFFIRMATION NOTE: You must sign this in front of a notary. A court clerk can provide this notary service for you at no charge. Bring a photo ID with you for the notarization. I swear or affirm that the above statements and any attachments are true to the best of my knowledge and belief. Date Signature of Person Filing Motion , Alaska Printed Name Subscribed and sworn to or affirmed before me at on . Date Clerk of Court, Notary Public or other person authorized to administer oaths. (SEAL) My commission expires: CERTIFICATE OF SERVICE [MUST BE COMPLETED] I certify that I served a copy of this motion and all the documents checked in paragraph 7 as shown below: parent.) Other Parent (Instructions: You must also send a Response Packet (DR-356) to the other I served the other parent with (1) a copy of this motion and all documents checked in paragraph 7 and (2) a Response Packet by first class mail hand-delivery Name of Other Parent: Address: Date mailed or hand-delivered: Other Parent's Attorney (Instructions: If the other parent was represented by an attorney within the last year, you must send the attorney a copy of this motion and all the documents checked in paragraph 7.) I served the attorney with a copy of this motion and all the documents checked in paragraph 7 by first class mail hand-delivery Name of Other Parent's Attorney: Address: Date mailed or hand-delivered: Signature of Person Filing Motion Page 3 of 3 Civil Rules 77, 90.3(d)(2) & (f)(5) DR-352 (3/16)(cs) American LegalNet, Inc. MOTION & AFFIDAVIT REQUESTING PAYMENT FOR CHILDREN'S HEALTH CARE EXPENSES www.FormsWorkFlow.com