WPC  [+ m&<2*'W\TBآB=awN{=zNbjU[Ε9~ՉQlgmːxy^>uUtusyr&$'*5ai$&zk맊r'e`ŷdg0 HE>$1sx i)6K8HAVON$H}JAQLvIWD;SIj?2:^[5\ȦKψ@+;oz;R>]?'B ~Q(P`Ԗ2XU7}G'`hHM>F*"G FQ$# %NU@^ w4+ 0(: 0Db m 0D"Terri Porter VSUPREME COURT OF THE STATE OF NEW YORK l,Converted by WordPort from source file mat024.doc ."0Kathy Hugheshp officejet v seriesT(,,,,T(0X(9 Z(Times New Roman k21 O2:i+003|x($(2#$  !  U(2#$  !   !  _  XX]XXXX0  Atan_I.A.S._ԀPart30ofthe  SupremeCourtoftheStateof  NewYork,heldinandforthe  Countyof__________,atthe t SupremeCourthouse, ` __________,NewYorkonthe L  _____dayof__________,20__.8 (#(#  PRESENT: $ t $N h$ N HON._________________,  8   N  h Justice. $  ---------------------------------------------------------------X   [NAME], \ *N *  Plaintiff,  IndexNo.___________  p **  -against-  QUALIFIEDMEDICAL 4      CHILDSUPPORTORDER $  [NAME],  ' '  Defendant.  --------------------------------------------------------------X H!  NOTICE:YOURWILLFULFAILURETOOBEYTHISORDERMAY,AFTERA  $\" COURTHEARING,RESULTINYOURCOMMITMENTTOJAILFORATERMNOT $H # TOEXCEEDSIXMONTHS,FORCONTEMPTOFCOURT.  %4!$ _  ThisQualifiedMedicalChildSupportOrder(_QMSCO_)ordersanddirectsthat: (#' *X*   Name    DateofBirth    SocialSec.No.    MailingAddress l+&*  JenniferJones  3/11/92  111-66-8888  35SmithAvenue X,'+       _Mineola_,NY11501 D-(, _ԇ0 r0isentitledtobeenrolledinandreceivethebenefitsforwhichthelegallyresponsiblerelatives  namedbelowareeligible,underthegrouphealthplanspecifiedbelowinaccordancewithSection  609oftheFederalEmployeeRetirementIncomeSecurityAct. t   TheParticipants(legallyresponsiblerelatives)are: 8  --   Name    DateofBirth    SocialSec.No.    MailingAddress   L  MaryJones  8/28/61  198-45-5678  35SmithAvenue  8        Mineola,NY11051 $  JohnJones  10/18/57  182-88-1332  21FifthStreet         GardenCity,NY11530     Thegrouphealthplanssubjecttothisorderare: H 3 hD r3   Name   Plan  h  IDNumber  D Plan   Mailing   \   h  D  Administrator    Address  H JohnJones OxfordFreedom h 1113333*01 D PortAuthority  1166Avenueofthe 4  Plan h  D ofNY&NJ  Americas     h  D   NewYork,NY10036   MaryJones BenefitPlan h 123-33-3333 D BenefitPlan  P.O.Box8915   Administrators h  D Administrators  Melville,NY11747 l $ $  ORDEREDthatthecoverageshallincludeallplanscoveringthehealth,medical,dental, 0"  pharmaceuticalandopticalneedsofthedependentnamedaboveforwhichtheParticipantis #l! eligible;anditisfurther $X"   ORDEREDthatclaimswillbesubmittedfirsttotheplaintiffscarrier,andtotheextentnot &"% paid,willthenbesubmittedtothedefendantscarrier;anditisfurther '#&   ORDEREDthatsaidcoverageforsaidchildshallbeeffectiveasof__________________, |*%) 20__,andshallcontinueasavailableuntilthechildattainstheageof21yearsoruntilthefurther h+&* orderofthisCourt. T,'+  @-(, Ї'p,'   p ENTER  *p * p ______________________________ t  p   J.S.C. ` *` pp*TO: ` PlanAdministrators $ t  ` NOTICE: PursuanttoSection5241oftheCivilPracticeLawandRules,ifan  8  employer,organizationorgrouphealthplanfailstoenrolleligibledependentsortodeductfrom (  thedebtorsincomethedebtorsshareofthepremium,suchemployer,organizationorgroup   healthplanadministratorshallbejointlyandseverallyliableforallmedicalexpensesincurredon   behalfofthedebtorsdependentsnamedintheexecutionwhilesuchdependentsarenotso   enrolledtotheextentoftheinsurancebenefitsthatshouldhavebeenprovidedundersuch   execution. t  ` Thegrouphealthplanisnotrequiredtoprovideanytypeorformofbenefitor 8 optionnototherwiseprovidedunderthegrouphealthplanexcepttotheextentnecessarytomeet $t therequirementsoftheUnitedStatesCode. `