National Medical Support Notice - Part B

NATIONAL MEDICAL SUPPORT NOTICE - PART B

MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR

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 (CSPIA). Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established under such 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 drug;  Mental health;  Other (specify):________________________

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1210-0113. The time required to complete this information collection is estimated to average five minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: G. Christopher Cosby, Office of Policy and Research, Department of Labor, Employee Benefits Security Administration, 200 Constitution Avenue NW. Room N–5718, Washington, DC 20210. The expiration date for the information collection is 03/31/2016.