ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

FL-478

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

REQUEST AND NOTICE OF HEARING REGARDING 
HEALTH INSURANCE ASSIGNMENT

CASE NUMBER:

NOTICE: If you object to the Application and Order for Health Insurance Coverage (form FL-470) or National Medical 
Support Notice (form OMB-0970-0222), complete and file this form with the court clerk to request a hearing. This form may 
not be used to modify your current child support amount. (See "Information Sheet on Changing a Child Support Order" on 
page 2 of form FL-192.) 

1.  A hearing on this application will be held as follows (see instructions for getting a hearing date on form FL-478-INFO):

a.       Date:

Time:

Dept.:

Div.:

Room:

b.   The address of the court is   

same as above   

other (specify):

2.

I request that service of the Application and Order for Health Insurance Coverage (form FL-470) or National Medical Support
Notice (form OMB-0970-0222) be quashed (set aside) because:

I am not the obligor named in the Application and Order for Health Insurance Coverage or National Medical Support 
Notice.
Health insurance coverage is not available at a reasonable cost.
The health insurance premium plus the monthly payment in any earnings assignment order are more than half of 
my total net income each month from all sources.
The following children (name):                                                                                                             are emancipated.  
I was not notified at least 15 days before the date of filing of the application that a health insurance coverage 
assignment was being sought.

No order to maintain health insurance has been issued.    

Health insurance coverage is or will be provided for the children, but not through a parent's job-related coverage 
(explain):   

The employer's choice of coverage is inappropriate (explain):          

a.

b.
c.

d.

e.

f.

g.

h.

i.

Other (specify):

Date:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

(cid:96)

(TYPE OR PRINT NAME OF PERSON REQUESTING HEARING)

(SIGNATURE OF PERSON REQUESTING HEARING)

Form Adopted for Mandatory Use 
Judicial Council of California 
FL-478 [New January 1, 2007]

REQUEST AND NOTICE OF HEARING REGARDING 
HEALTH INSURANCE ASSIGNMENT 
(Family Law—Governmental—UIFSA)

Page 1 of 2

Family Code, §§ 3761, 3765, and 3773 
www.courtinfo.ca.gov

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

CASE NUMBER:

FL-478

NOTICE FOR CASES INVOLVING A LOCAL CHILD SUPPORT AGENCY

This case may be referred to a court commissioner for hearing. By law, court commissioners do not have the authority to issue final 
orders and judgments in contested cases unless they are acting as temporary judges. The court commissioner in your case will act 
as a temporary judge unless, before the hearing, you or any other party objects to the commissioner acting as a temporary judge. 
The court commissioner may still hear your case to make findings and a recommended order. If you do not like the recommended 
order, you must object to it within 10 court days; otherwise, the recommended order will become a final order of the court. If you 
object to the recommended order, a judge will make a temporary order and set a new hearing.            

I certify that I am not a party to this action and that a true copy of the Request and Notice of Hearing Regarding Health Insurance  
Assignment (form FL-478) was mailed, with postage fully prepaid, in a sealed envelope addressed as shown below, and that the request 
was mailed at (place):

on (date):

CLERK’S CERTIFICATE OF MAILING

Date:

Clerk, by

, Deputy

Request for Accommodations
Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter services are available if 
you ask at least five days before the proceeding.  Contact the clerk's office or go to www.courtinfo.ca.gov/forms for 
Request for Accommodations by Persons With Disabilities and Response (form MC-410).  (Civil Code, § 54.8)

FL-478 [New January 1, 2007]

Page 2 of 2

REQUEST AND NOTICE OF HEARING REGARDING 
HEALTH INSURANCE ASSIGNMENT 
(Family Law—Governmental—UIFSA)