E instructions to complete the Request and Notice of Hearing Regarding Health Insurance Assignment (form FL-478) if you do not have an attorney representing you. Your attorney, if you have one, should complete this form. You must file the completed Request and Notice of Hearing form and its attachments with the court clerk within 15 days after the date your employer gave you a copy of Application and Order for Health Insurance Coverage (form FL-470) or National Medical Support Notice (form OMB-0.
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How to fill out the FL 478 Info Form online
Filling out the FL 478 Info Form online can seem daunting, but this guide will walk you through the process step-by-step. By following these instructions, you can ensure that your form is completed accurately and submitted on time.
Follow the steps to complete the FL 478 Info Form online
- Click 'Get Form' button to access the form and open it in your preferred digital editor.
- Enter your personal details in the first box on the top left side of the front page. Provide your full name, address, and telephone number if they are not already populated.
- Navigate to Item 1. Contact the court clerk's office to inquire about the procedures for obtaining a hearing date related to your request.
- In Item 2, select the box if you wish to stop the local child support agency or the other parent from collecting health insurance premiums from your earnings. Make sure to check at least one of the following boxes that apply to your situation:
- Under Item 2, check the relevant boxes as follows: (a) if you are not responsible for paying health insurance premiums, (b) if coverage is not available at a reasonable cost, (c) if the total health insurance premium exceeds half of your net income, (d) if the children are emancipated, (e) if you were not notified 15 days prior to filing, (f) if there is no court order for you to maintain coverage, (g) if you or another party will provide coverage, (h) if the employer's coverage choice is inappropriate, or (i) if you have another reason against enforcement.
- Date the form, type or print your name, and sign under penalty of perjury. Your signature confirms the accuracy of the information you provided.
- Complete the certificate of mailing on page 2: list the other parties' names and addresses in brackets, and include a stamped envelope addressed to each. Do not sign or date this page.
- Ensure that the completed form is filed with the court clerk within 15 days of receiving the Application and Order for Health Insurance Coverage or National Medical Support Notice. You may submit it in person or by mail.
- After filling out the form, save your changes to keep a copy for your records. You can also download, print, or share the form as needed.
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