1 STATE OF TEXAS. Date: Custodial Parent: Non-Custodial Parent: Attorney General Case Cause

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1 OFFICE OF THE ATTORNEY GENERAL MEDICAL SUPPORT UNIT P0 BOX 1328 AUSTIN, TX Toll Free: 1/800/ Fx: 512/ OFFICE OF THE ATTORNEY GENERAL STATE OF TEXAS CHILD SUPPORT DIVISION Greg Abbott Attorney Generl DALLAS CITY OF ATTN: EGBERT HOOD ATTN: RM L1END 1500 MARILLA ST CITY DALLAS, TX CO Dte: Custodil Prent: NonCustodil Prent: Attorney Generl Cse Cuse #: #: RE: Der Employer: Enclosed bove on the NMSN. Ntionl Medicl Support Notice (NMSN) mndted by to obligted by There re two prts to the NMSN: Prt A required Notice court or dmtrtive child support order federl regultions. The employee identified provide helth cre coverge for the child(ren) lted to Withhold fri Helth Cre Coverge, directs the employer to withhold employee contributions by the group helth :tn(s) the Prt group helth pln (e.g., medi& or dentl) B Medicl Support No ic. to which the child(ren) /re enrolled; nd Pln Admtrtor, tht must to enroll the eligible child(ren). forwrded to the dmtrtor of ech PLEASE RETURN EITHER THE PL0YER AND PLAN ADMINISTRATOR RESPONSE FORMS FROM PART A OR PART B TO THE ADiRESS LISTED BELOW. The employer s duties, responsibilities nd time frmes re ddressed ccompny the NMSN. Also enclosei re the followg dditionl forms: Employer Helth Insurnce Enrollment Informtion Form tht must nd returned to the ddress low; nd Helth Insurnce Sttus Chnge Form tht must coverge chnges or lpses. When the child(ren) /re lredy enrolled nother helth surnce pln or medicl support order, ccess the employer website t the response forms nd structions tht completed with enrollment formtion completed nd returned to the ddress low when surnce ccordnce with previous child support to obt the form to notify the Office of the Attorney Generl. If th sitution occurs, th form Plese do Scerely, not hesitte to contct us submitted lieu of NMSN Prt A Response. t (800) if you hve ny questions regrdg the NMSN. OFFICE OF THE ATTORNEY MEDICAL SUPPORT UNIT PU BOX 1328 AUSTIN, TX PH: 1/800/ FAX: 512/ GENT.AL Enclosure

2 ATlONAL MEDiCAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE Ib Notice sued under Section 466()(19)the Socil Security Act, section 609()(5)(c) of the Employee Retirement Income Security Act of 1974 (ERISA), nd for Stte nd locl governmfnt nd church plns, sections 401(e) nd Receipt of th Notice from the sug Agency constitutes receipt of Medicl Child Support Order under pplicble lw. The formtion on the Custodil prent nd Child conted on th pge confidentil nd should not shred on dclosed with the Noncustodil Prent. (1) of the Child Support Performnce nd Incentive Act of sug Agency: Office of the Attorney Generl Court or 301ST DISTRICT COURT Child Support Divion Admtrtive Authority: DALLAS County, Texs MEDICAL SUPPORT UNiT Issug Agency Address: P0 BOX 1328 Dte of Support Order: AUSTIN. TX Dte of Notice: Support Order Numr: Cse Numr: Telephone Numr: (800) FAX Numr: 5 12/ Employer web site: www,employer.ti.stte.tx. us Employer/Withholder s Federl E1N Numr ) RE: Employees Nme (Lst, First, Ml) DALLAS CITY OF Employer s/withholder s Nme Employee s Socil Security Numr ATTN: RM L1END 1500 MARILLA ST CiTY CO DALLAS TX Employer s/withholder s Address Employee s Milg Address Custodil Prent s Nme (Lst, First, MI) Substituted Officil/Agency Nme nd Address (Required if Custodil Prent s milg ddress left blnk) Custodil Prents Milg Address Child s Milg Address (if different from Cuslodil Prent s) ) Attorney Generl Child Support Divion MEDICAL SUPPORT UNIT P 0 BOX 1328, AUSTIN TX Telephone Numr: 1/800/ FAX 5/ Nme, Milg Address, nd Telephone Nun er of Representtive of the Child ChiId(ren)s Nme [lob Child(ren) s Nme SSN BOB SSN The order requires the child to enrolled [1 my helth coverges vilble; or [X X Medicl Dentl Vion Presur rtion Drug Mentl Helth Other (specity): I only the followg coverge(s): THE PAPERWORK REDUCTION ACT OF 1995 (P.L. I U 13) Public reportg burden for th collection of formtion estimted to verge 10 mutes per response, cludg the time reviewg structions. gthermg nd mtmg the dt n :ced, nd reviewg the collection formtion An gency my not conduct or sponsor, nd person not required to respond to, collection of formtion unless it dplys currently MB control numr control numr; vs1e 0MB of Employer Nme: DALLAS Employer Federl EIN: CITY OF NonCustodil Prent: NonCustodil Prent: OAG Cse Numr: NATIONAL MEDICAL SUPPORT NOTICE MEDICAL SUPPORT WITHHOLDING PART A

3 Nme: CITY Telephone EMPLOYER RESPONSE If 1, 2, 3 or 4 low pplies, check the pproprite box nd return th Prt A to the Issug Agency with 20 busess dys fter the dte of the Notice, or sooner if resonble, NO OTHER ACTION IS NECESSARY. If 1, pproprite pln dmtrtor(s) with orgniztion or lbor union tht provides gc up helth cre nefits to the employee. Check nunir 2G 2, 3 or 4 do not pply, forwrd Prt B to the busess dys fter the dte of the Notice, or sooner if resonble. Th cludes ny 5 nd return th Prt A to the Issug Agency if the Pln Admtrtor jorms you tht the child would enrolled or qulifies for n option under the pln for which you hve determed tht the emplcee contribution exceeds the mount tht my withheld from the employee s come due to Stte or Federl withholdg lmiittionc ridlor prioritiztion You re required to respond to the sug Agency by returng the Employer Response regrdless of whether ou provide group helth nefits or the employee nmed here your orgniztion. Informtion on the Empoyer Representtive t the bottom of th section I. The employee nmed th Notice hs never en employed by th employer. required. no longer employed by 2. We, the employer, do not mt or contribute to plns providg dependent or fmily helth cre coverge to our employees. 3. The employee mong clss of employees (for exmple, prttime or nonunion) tht re not eligible for fmily helth coverge under ny group helth pln mted by the employer or to which the employer contributes. Do not check th only temporrily eligible for helth cre coverge. box if the employee 4. Helth cre coverge not ilble cuse employee no longer employed by the employer: Dte termtion: Lst krown ddress: Lst krown telephone numr: New enployer (if known): New niployer ddress: 5 New ployer telephone numr: Stte or Federl withholdg rnittions ndlor prioritiztion prevent the withholdg from the employee mount required to obt cover under the terms of the pln s come of the Employer Representtive (Required): Title: Numr: Dte: Federl EIN (if not provided by the Issug Agency on Pge Coverge): 1 of th Notice to Withhold for Helth Cre ISSUiNG AGENCY: OFFiCE OF Child Support Divion P0B0X1328 AUSTIN FX78767 (800) THE ATTORNEY GENERAL MEDICAL 1328 SUPPO;U UNIT Employer Nme: DALLAS OF NonCustodil Prent: NonCustodil Prent SSN Employer Federl E1N: OAG Cse Numr: NATIONAL MEDICAL SUPPORT NOTICE EMPLOYERS instructions

4 instructions TO EMPLOYER Th document serves s legl notice tht the employee identified on th Ntionl Medicl Support Notice obligted by court or dmtrtive child support order to provide helth cre coverge for the child identified on th Notice. Th Ntionl Medicl Support Notice replces ny Medicl Support Notice tht the sug Agency hs previously served on you with respect to the employee nd the child lted on th Notice. The document consts of Prt A Notice to thhold for Helth Cre Coverge for the employer to withhold ny employee contributions required by the group helth pln(s) which child enrolled; nd Prt B Support Notice to the Pln Admtrtor, which must forwrded to the dmtrtor of ech grou helth pln identified by the employer to enroll the eligible child, or completed by the employer, if the employer serves s the helth pln dmttor Medicl An employer receivg th legl Notice req ed to complete nd return Prt A if pproprite. If group helth coverge not vilble to the employee nmed here, or the employee ws i:ver or no longer employed, the employer still required to complete Prt A Employer Response nd return it to the Issug Agency ih the pproprite response checked. if you. the employer, provide the helth cre nefits to the employee, forwrd Prt B Pln Admtrtr Response to the helth pln dmtrtor of your orgniztion. If the employee s helth cre nefits re dmtered through nother org tion, cludg ctg s the pln dmtrtor for completion If the employee hs lredy enrolled the child helth cre coverge, the employer must forwrd Prt B to the pln dmtrtor for completior nd submittl to the Issug Agency. lbor union, forwrd Prt B of the notice to the lbor union or other orgniztion Keep copy of Prt A s it my used to nutty the sug Agency t ny time the future the employee seprtes from service for ny reson cludg retirement or termtion. EMPLOYER RESPONSIBILiTIES 1. If the dividul nmed th notice ; not your employee, or if fmily helth cre coverge not vilble, plese complete item or 4 of the Employer Response s pproprite, nd return it to the Issug Agency. NO FURTHER ACTION IS NECESSARY. 1, 2, 3 2. If fmily helth cre coverge vilble for which the child identified bove my eligible, you re required to:. Trnsfer, not lter thn 20 busess dys fter the dte of th Notice, copy of Prt B Medicl Support Notice to the Pln Admtrtor to the dmtrtor of ech pproprite group helth pln for which the child my eligible, nd b. Upon notifiction from the pln dmtrtor(s) tht the child enrolled, either I) withhold from the employee s come ny employee contributions required under ech group helth pln, ccordnce with the pplicthle lw of the employee s prcipl plce of employment nd trnsfer employee contributions to the pproprite pln(s), or 2) complete iter of the Employer Response to notify the Issug Agency tht enrollment cnnot completed cuse of prioritiztion ct) mittions on withholdg c. if the pln dmtrtor nctifies you tht the employee subject to witg period tht expires more thn 90 dys from the dte of its receipt of Prt B oft Notice, or whose durtion determed by mesure other thn the pssge of time (for exmple, the completion of certiii umr of hours worked), notify the sug gency of the enrollment time frme nd notify the pln dmtrtor when the emjoyee eligible to enroll the pln nd tht th Notice requires the enrollment of the child nmed the Notice the pln. Employer Nme: DALLAS CITY OF NonCustodil Prent: NonCustodil Prent SSN: Employer Federl EIN: OAG Cse Numr: NATIONAL MEDICAL SUPPORT NOTICF MPLOYERS INSTRUCTIONS 2

5 LIMITATIONS ON WITHHOLDING The totl mount withheld for both csh nd meiicl support cnnot exceed the pplicble Consumer Credit Protection Act (CCPA) percentge (%) of the employee s ggregte dposble weekly :rng. The employer my not withhold more under th Ntionl Medicl Support Notice thn the lesser of: 1. The mounts llowed by the Federl Consumer Credit Protection Act (15 U.S.C., section 1673(b)); 2. The mounts llowed by the Stte of the employee s prcipl plce of employment; or 3. The mounts llowed for helth surnce premiums by the child support order, s dicted here: The Federl limit pplies to the ggregte dposble weekly erngs (ADWE). ADWE the net come left fter mkg mndtory deductions such s Stte, Federl, locl txes; Socil Security txes nd Medicre txes. As required under section 2.b.2 of the Employer Responsibilities on the prior pge, complete item limittions on withholdg. 5 of the Employer Response to notify the Issug Agency tht enrollment cnnot completed cuse of prioritiztion or PRIORITY OF WITHHOLDING If withholdg required for employee contribilions to one or more plns under th notice nd for support obligtion under seprte notice nd vilble funds re sufficient for withhold tor both csh nd medicl support contributions, the employer must withhold mounts for purposes of csh support nd medicl support contributims ccordnce with the lw, if ny, of the Stte of the employee s prcipl plce of employment requirg prioritiztion tween csh nd med cl support, s descrid here: Texs lw requires tht the employee contributions for helth surnce re withheld first fore withholdgcr csh support (csh child support, csh medicl support, or csh spousl support). [ lfc If n employer fced with two or more NMSNs nd cnnot comply with ll of the notices, the employer should comply with the notices the order which they were first received. As reonired under section 2.b.2 of the Employer Responsibilities on prior pge, complete item Employer Response to notify the Issug Agency tht enrollment cnnot completed cuse of prioritiztion or limittions on withholdg. DURATION OF WITHHOLDING 5 of the lol.oloj The child shll treted s dependent und ie terms of the pln. Coverge of the child s dependent will end when conditions for eligibility lbr coverge under terms of the pln no longer c,ply. However, the contution of coverge provions of ERISA my entitle the child to contution of coverge under the pln. The coverge for) the child unless: go :ployer must contue to withhold employee contributions nd my not denroll (or elimte I. The employer provided stfctory written evidence tht:. The court or dmtrtive child support order referred to th Notice no longer effect; or b. The child or will enrolled comprble coverge which will tke effect no lter thn the effective dte of d enrollment from the pln; or 2. The employer elimtes fmily helth coverge for ll of its employees. Employer Nme: DALLAS CITY OF NonCustodil Prent: NonCustodil Prent SSN: Employer Federl EIN: OAG Cse Numr NATIONAL MEDICAL SUPPORT NOTICE MPLOYERS INSTRUCTIONS 3

6 POSSiBLE SANCTIONS An employer my subject to snctions or perlties imposed under Stte lw nd/or ERISA for dchrgg n employee from employment, refusg to employ, or tkg dciplry ctk: gst ny employee cuse of medicl child support withholdg, or for filg to withhold come, or trnsmit such withheld mounts to t pplicble pln(s) s the Notice directs. Snctions or penlties my imposed under Stte lw gst n employer for filure to respond nd/ for noncomplince with th Notice. NOTiCE OF TERMiNATION OF EMPLO MENT ny cse which the bove employee s empoyment termtes, the employer must promptly notify the sug Agency lted low of such termtion. Th requirement my stfied y sendg to the Issug Agency copy of Prt A with response 4 checked, or ny notice the employer required to provide under the cont ition of coverge provions of ERISA or the Helth Insurnce Portbility nd Accountbility Act. EMPLOYEE LIABILITY FOR CONTRIBLTION TO PLAN The employee lible for ny employee contributions tht re required under the pln(s) for enrollment of the child nd subject to pproprite enforcement. The employee my contest the withholdg under th Notice bsed on employee contest the withholdg under th Notice, the employer must proceed to comply with the employer responsibilities th Notice until notified by the Issug Agency to dcontue withholdg. To contest the withholdg under th Notice, the employee should contct the Issug mtke of fct (such s the identity of the obligor). Should n Agency t the ddress nd telephone numr lted low on the Notice. With respect to plns subject to ER1SA, it the view of the Deprtment of Lbor tht Federl Courts hve jurdiction if the employee chllenges determtion tht the Notice constitutes Qulified Medicl Child Support Order. CONTACT FOR QUESTIONS if you hve ny questions regrdg th Notice, you my contct the sug Agency t the ddress nd telephone numr lted low. dicte low to the sug Agency the requerled formtion on your Pln Admtrtor to whom Prt forwrded for completion. B Pln Admtrtor Response Pln Admtrtor (Required): Nme: Contct Phone: Telephone Numr: FAX Numr: ISSUING AGENCY: OFFICE OF TF]E A itorney GENERAL Child Support Divion POBOX 1328 AUSTIN, TX (800) MEDICAL SUPPO UNiT Employer Nme: DALLAS CITY OF NonCustodil Prent: NonCustodil Prent SSN: Employer Federl EIN: OAG Cse Numr: NATtONAI, MEDICAL SUPPORT NOTtCE EMPLOYERS INSTRUCTIONS

7 DALLAS _ Mentl NATIONAL MEDICAL SUPPORT PART B MEDICAL SUPPORT NOTICE TO PLAN ADMiNISTRATOR Th Notice sued under Section 466()(19) of the Socil Security Act, section 609()(5)(c) of the Employee Retirement come Security Act of 1974, nd for Stte nd locl government nd church plns, sections 401(e) nd (1) of the Child Support Performnce nd Incentive Act of 1998: Receipt of th Notice from the Issug Agency constitutes receipt of Medicl Child Support Order under pplicble lw. The rights of the prties nd the duties of the pln dmtrtor under th Notice re ddition to the extg right nd duties estblhed under such lw. Issug Agency: Office of the Att:rney Generl Court or 301ST DISTRICT COURT Child Support Dvion Admtrtive Authority: DALLAS County, fexs MEDiCAL SUP ORT UNIT Issug Agency Address: P 0 BOX 1328 Dte of Support Order: AUSTIN, TX 7W Dte of Notice: 4/15/2011 Support Order Numr: Cse Numr: Telephone Numr: (800) FAX Numr: 512/ Employer web site: ) RE BRIONES, VALENTE Employer/Withholder s Federl EIN Numr Employee s Nme (Lst, First. Ml) CITY OF Employer s/withholder s Nme Employee s Socil Security Numr ) ATTN:RMLIENDC1lYCO 1500 MARILLA ST Employee s Milg Address DALLAS TX Employer s/withholder s Address Custodil Prent s Nme (Lst, First, MI) Custodil Prent s Milg Address Substituted Officil/Agency Nme nd Address (Required if Custodil Prent s milg ddress left blnk) Child s Milg Address (if different from C odil Prent s) Attorney Generl Child Support Divion MEDICAL SUPPORT UNIT P 0 BOX 1328, AUSTIN TX Telephone Numr: 1/800/ FAX ii/279l723 Nme, Milg Address, nd Telephone Nur:er of Representtive of the Child Chld(ren) s NmeBOB SSN Child(ren) s dme DOB SSN The order requires the child to enrolled Medicl Dentl Vion Prescrption Drug j ny helth coverges vilble; or [X Helth Other (specify): j only the followg coverge(s): Employer Nme: DALLAS Employer Federl EIN: CITY OF NonCustodil Prent: BRIONES, VALENTE NonCustodil Prent SSN: OAG Cse Numr: T NATIONAL MEDICAL SUPPORT NOTiCE TO PLAN AV1NISTRATOR RESPONSE

8 if ny: pln. (cludes _. PLAN ADMINISTRATOR RESPONSE (To completed nd returned to the lssuiiw. Agency, lted low, with 40 busess dys fter the dte of the Notice, or sooner if resonble) Th Notice ws received by Th Notice ws determed Response 2 or 3, nd the pln dmtrtor 4, to if pplicble. on qulified medicl child support order, on The prticipnt (employee) nd lternte recipient(s) (child) re coverge. O. b. o The child only one type of coverge provided under the There prticipnt under the pln. o c. d. The prticipnt The prticipnt currently enrolled enrolled the sme option. enrolled provtded coverge will Coverge Notice). The child hs en enrolled effective sof// n the pln option tht s to enrolled dependent of the prticipnt. pln. The child child cluded the followg fmily providg dependent coverge nd the child will s Complete dependents of the enrolled n option tht permits dependent coverge tht hs not en elected; dependent the followg option: witg period of necessry withholdg should commerce if the employer determes tht withholdg ndlor prioritiztion limittions. 3. There less it thn more thn one option vilble under the pln nd the prticipnt s must select from the vilble options. Ech child to cluded 90 dys from dte of receipt of th Any permitted under Stte nd Federl not enrolled. The Issug Agency dependent under one of the vilble options tht provide fmily coverge. If the sug Agency does not reply with busess dys of the dte th Response returned thc itld, nd the prticipnt if necessry will enrolled 20 the pln s defult option The prticipnt subject tn t witg period tht expires //_ (more thn dte of receipt of th Notice) or hs not completed the completion of thn the pssge of time, enrollment. such s ). Th Notice does not const 1tute The nme of the []child or [J prticipnt The milg ddress of the [] child (or The followg child t Pln Admtrtor or Representtive: witg period which 90 dys from the determed by some mesure other cert numr of hours worked (descri here: At the completion of the witg period, the pln dmtrtor will process the or bove the qulified medicl child support order cuse: unvilble. or ge t which dependents re no longer eligible for coverge under the substituted officil) [j prticipnt [sert nme(s) of child]. Nme: Telephone Numr: Title: Address: ISSUING AGENCY: OFFICE OF THE ATTORNEY GENERAL Child Support I)ivion MEDICAL SUPPORT UNIT POE3OX1328 AUSTIN, TX (800) Dte: unvilble. Employer Nme: DALLAS CITY OF NonCustodil Prent: I NonCustodil Prent SSN: Employer Federl E1N: OAG Cse Numr: NATIONAL MEDICAL SUPPORt NOTICE TO PLAN,j:M1NIsTRAIOR RESPONSE

9 INSThUCTIONS TO PLAN ADMINISTRATOR Th Notice hs en forwrded from the employer identified bove to you s the pln dmtrtor of group helth pln mted by the employer (or group helth pln to which the employer contributes) nd which the noncustodil prent/prticipnt identified ove enrolled or eligible for enrollment Th Notice serves to form you tht the noncustodil prent/prticipnt obligted by n order sued by the court or gency identified bove to provide heth cre coverge for the child under the group helth pln(s) s descrid on Prt B. (A) If the prticipnt nd child nd their milg ddresses (or tht of Substituted Officil or Agency) re identified bove, nd if coverge for the child or will come vilble, th Notice constitutes qulified medicl child support order (QMCSO) under ER1SA or CSP1A, s pplicble. (If ny milg ddress not present, but it resonbly ccessible, th Notice will not fil to QMCSO on tht bs.) You must, with 40 busess dys of the dte of th Notice, or sooner if resonble: (I) Complete Prt B () if you checked Response 2: Pln Admtrtor Response nd send it to the sug Agency: (I) notify the noncustodil prent/prticipnt nmed bove, ech nmed child, nd the custodil prent tht coverge of the child or will come vilble (notifiction of the custodil prent will deemed notifiction of the child if they reside t the sme ddress); (ii) furnh the custocil prent description of the coverge vilble nd the effective dte of the coverge, cludg, if not lredy provided, summry pln description nd ny forms, documents, or formtion necessry to effectute such coverge, s well s formtion necessry to submit clims for nefits; (b) if you checked Response 3 (1) if you hve not lridy done so, provide to the sug Agency copies of pplicble summry pln descriptions or other docume ii tht descri vilble coverge cludg the dditionl prticipnt contribution necessry to obt coverge o the child under ech option nd whether there limited service re for ny option; (ii) if the pln hs eiult option, you re to enroll the child the defult option if you hve not received n election from the sug Agency with 20 busess dys of the dte you returned the Response. if the pln does not hve defuft option, you re to enroll the child the option selected by the Issug Agency. (c) if the prticipnt subject to witg period tht expires more thn 90 dys from the dte of receipt of th Notice, or hs not completed witg period whose durtion determed by mesure other thn the pssge of time (for exmple, the completion of cert numr of hours worked), complete Response 4 on the Pln Admtrtor Response nd return to the employer nd the Issug Agency, nd notify the prticipnt nd the custodil prent; nd upon stfction of the period or requirement, complete enrollment under Response 2 or 3, nd CiTY OF NonCustodil Prent: NonCustodil Prent SSN: Employer Federl E1N: OAG Cse Numr: Employer Nme: DALLAS NATiONAL MEDiCAL SUPPORT NOTICE TO PLAN ADMiNISTRATOR INSTRUCTIONS PAGE i OF 3

10 _ (d) upon completion of the enrollment, trnsfer the pplicble formtion on Prt B Pln Admtrtor Response to the employer for determtion tht the necessry employee contributions re vilble. Inform the employer tht the enrollme it pursunt to Ntionl Medicl Support Notice. (B) If with 40 busess dys of the dte of th Notice, or sooner if resonble, you determe tht th Notice does not constitute QMCSO, you must complete Response 5 of Prt B Pln Admtrtor Response nd send it to the Issug Agency, nd form the noncustodil trent/prticipnt, custodil prent, nd child of the specific resons for your determtion. (C) Any required notifiction of the costodil prent child nd/or prticipnt tht required my stfied by sendg the prty copy of the Pln Admtrtor Response, if pproprite. UNLAWFUL REFUSAL TO ENROLL Enrollment of child my not denied on the ground tht: (1) the child ws born out of wedlock; (2) the child not climed s dependent on the prticipnt s Federl come tx return; (3) the child does not reside with the prticipnt or the pln s service re; or (4) cuse the child receivg nefits or eligible to receive nefits under the Stte Medicid pln. If the pln requires tht the prticipnt enrolled order for the child to enrolled, nd the prticipnt not currently enrolled, you must enroll both the prticipnt nd the child. All enrollments re to mde without regrd to open seson restrictions. PAYMENT OF CLAiMS A child covered by QMCSO, or the child s custodil prent, legl gurdin, or the provider of services to the child, or Stte gency to the extent ssigned the child s rights, my file clims nd the pln shll mke pyment for covered nefits or reimbursement directly to such prty. PERIOD OF COVERAGE The lternte recipient(s) shll tre e d s dependents under the terms of the pln Coverge of n lternte recipient s dependent will end when similrly tited dependents re no longer eligible for coverge under the terms of the pln. However, the contution coverge p ovions of ERISA or other pplicble lw my entitle the lternte recipient to contue coverge under the pln. On e child enrolled the pln s directed bove, the lternte recipient my not denrolled unless: (1) The pln dmtrtor pxovided stfctory written evidence tht either () the court or dmtrtive child support order referred to bove no longer effect, or (b) the lternte recipient or will enrolled comprble coverge which will tke effect no lter thn the effective dte of denrollment from the pln; (2) The employer elimtes fmily helth coverge for ll of its employees, or (3) Any vilble contution overge not elected, or the period of such coverge expires. Employer Nme: DALLAS CITY OF NonCustodil Prent: NonCustodil Prent SSN Employer Federl EIN: OAG Cse Numt: NA i ional MEDICAL SUPPORI NOl ice to PLAN f) 11NiS FRA FOR instructions PAGE 2 OF.

11 MEDiCAL CONTACT FOR QUESTIONS if you hve ny questions regrdg th Notice, you my contct the sug Agency lted low. the ddress nd telephone numr Pperwork Reduction Act Notice The Issug Agency sks for the formtion Income Security Act th form on to lw s or the Child Support Performnce nd Incentive Act, s to to crry out the specified pplicble. You re required to give the dplys the Employee Retirement sug Agency the formtion. You re not required currently vlid 0MB control numr. The Issug Agency needs the formtion to determe whether helth cre coverge file the form respond provided estimted low. These times will vry dependg th collection of formtion unless ccordnce with the underlyg child support order. The Averge time needed to complete nd on the dividul circumstnces. it Lerng bout the Jw or tiie form Preprg the form First Notice 1 hr. 1 hr., 45 mm. Subsequent 35mm. Notices ISSUING AGENCY: OFFICE OF THE ATTORNEY GENERAL Child Support Divion SUPPORT UNIT BOX 1328 AUSTIN. TX (800) P0 Employer Nme: DALLAS CITY OF Employer Federl EIN: NonCustodil PrentL NonCustodil OAG Cse Nun i NATIONAL MEDICAL SUPPORT NOTICE TO PLAN /Ot IIN1SIRATOR INSTRUCI IONS PAGE 3 OF 3