Revisions

Changes to the NMSN Part A

NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE – page 1

1) In the Header paragraph, added a new second sentence, “Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law.”

2) In the Header paragraph, added a new third sentence, “The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the Noncustodial Parent.”

3) In the agency information box, added space for the State “Employer web site.”

4) After the Employer, Custodial Parent and Children’s Mailing Address lines, deleted the nine open ended parentheses.

5) On the Employer’s Name line, after RE, replaced the asterisk (*) with a colon (:).

6) Below the “Substituted Official/Agency Name and Address” line, added (Required if Custodial Parent’s mailing address is left blank.)

7) At the bottom of the page, added the new expiration date: xx/xx/xxxx.

EMPLOYER RESPONSE – page 2

8) In the first sentence, deleted the word “either”.

9) In the first sentence, changed “1, 2 or 3” to “1, 2, 3 or 4”.

10) In the third sentence, deleted the words “neither”, “nor” and “applies” and modified to read, “If 1, 2, 3 or 4 do not apply, forward Part B…”

11) Added as the fourth sentence,” This includes any organization or labor union that provides group health care benefits to the employee.”

12) In the fifth sentence, was modified to read, “Check number 5 and return this Part A to the Issuing Agency if the Plan Administrator informs you that the child(ren) would be enrolled in or qualify(ies) for an option…”.

13) Added as the sixth sentence, “You are required to respond to the Issuing Agency with the Employer Response regardless of whether you provide group health benefits or the employee named herein is no longer employed by your organization.”

14) Added as the seventh sentence, “Information on the Employer Representative at the bottom of this section is required.”

15) Added a new check box # 1 that reads, “The employee named in this Notice has never been employed by this employer.”

16) The remaining check boxes have been renumbered: 1 is now 2, 2 is now 3, 3 is now 4, and 4 is now 5.

17) In check box # 2, language was changed to read, “We, the employer, do not maintain or contribute to plans providing dependent or family health care coverage to our employees.”

18) In check box # 3, added a second sentence that reads, “Do not check this box if the employee is only temporarily ineligible for health insurance.”

19) At the bottom of the page after “Employer Representative” added the word “(Required)”.

20) At the bottom of the page, modified the last sentence added the word “Federal” before EIN and added the words “Page 1 of this” before the word Notice.

INSTRUCTIONS TO EMPLOYER – page 3

21) In the first paragraph, first sentence, added the word “legal” before the word “Notice”.

22) In the first paragraph, third sentence was moved and modified to the third paragraph, fifth sentence.

23) In the second paragraph, first sentence, bolded the word “must”.

24) Added a new third paragraph that reads, “An employer receiving this legal Notice is required to complete and return Part A if appropriate. If group health coverage is not available to the employee named herein, or the employee was never or is no longer employed, the employer is still required to complete Part A – Employer Response and return it to the Issuing Agency with the appropriate response checked. If you, the employer, provide the health care benefits to the employee, forward Part B – Plan Administrator Response to the health plan administrator of your organization. If the employee’s health care benefits are administered through another organization, including a labor union, forward Part B of the Notice to the labor union or other organization acting as the plan administrator for completion. If the employee has already enrolled the child(ren) in health care coverage, the employer should forward Part B to the plan administrator for completion and submittal to the Issuing Agency.”

25) Added a new fourth paragraph that reads, “Keep a copy of Part A as it may be used to notify the Issuing Agency at anytime in the future the employee separates from service for any reason including retirement or termination.”

EMPLOYER RESPONSIBILITIES – page 3

26) In item # 1, first sentence, replaced the word “above” with “in this Notice”.

27) In item # 1, first sentence, changed “1, 2, or 3” to “1, 2, 3 or 4”.

28) In item # 2(b)(2), changed “4” to “5”.

29) In item # 2(c), un-bold the word “of” after “Part B”.

LIMITATIONS ON WITHHOLDING – page 4

30) In last paragraph, third sentence changed “4” to “5”.

PRIORITY OF WITHHOLDING – page 4

31) In the last sentence, changed “4” to “5”.

DURATION OF WITHHOLDING – page 4

32) In the first paragraph, second sentence was modified to read, ”Coverage of a child as a dependent will end when conditions for eligibility for coverage under the terms of the plan no longer apply.”

33) In item # 1(a), deleted the word “above” and replaced with “in this Notice.”

POSSIBLE SANCTIONS – page 5

34) Added a second sentence that reads, “Sanctions or penalties may be imposed under State law against an employer for failure to respond and/or for non-compliance with this Notice.”

NOTICE OF TERMINATION OF EMPLOYMENT – page 5

35) In the second sentence, added the words, “Part A with response 4 checked or…”

CONTACT FOR QUESTIONS – page 5

36) In the first sentence, replaced the word “above” with “at page 1 of this Notice.”

37) Added a new second paragraph that reads, “Indicate below to the issuing Agency the requested information on your Plan Administrator to whom Part B – Plan Administrator Response is forwarded for completion.”

38) Added at the bottom of the page to read, “Plan Administrator (Required):”

39) Added fields at the bottom of the page for Plan Administrator information: “Name, Telephone Number, Contact Person, and FAX Number”.

3