TO:

Obligor’s name and address

COMPLAINT

    order.

 expenses that are more than the annual ordinary medical amount that can be collected as specified in the support 

I request the friend of the court to enforce health-care expenses. Attached is the request for health-care expense payment
(including all supporting documents) given to the obligor. I declare that:
1. I requested payment within 28 days of the date notified of the balance due after insurance payments.
2. This request is for
 
 
 
3. This complaint is
 
 
 
4. As of this date, the expense information in the attached request for health-care expense payment is true except as 
 

 within six months after the date of the insurer’s final denial of coverage for the expense.
 within one year of the date the expense was incurred.
 within six months after the obligor’s default of an agreement to repay (copy of agreement attached).

follows: Since the date I mailed the request for health-care expense payment to the obligor, the obligor paid 

 health-care expenses that have been incurred by the payer of support.

  $ 
 

Date

Name(s) of child(ren)

 for 

 

 and 

Name(s) of medical provider(s)

 .

Signature

NOTICE

The friend of the court has been asked to enforce health-care expenses. Unless you file a written objection with the friend 
of the court within 21 days of the date this notice is sent, the expenses will be added to your support account as a 
health-care support arrearage for enforcement and must be paid 
per month, except that the full balance will be subject to immediate enforcement.

  in full by 
 

  $ 
 

 . 

 

 

 

If you timely file a written objection in the manner required, a hearing will be set to resolve the health-care complaint.

I served a copy of this complaint on the parties or their attorneys by first-class mail addressed to their last-known addresses 
as defined by MCR 3.203. I declare under the penalties of perjury that this certificate of mailing has been examined by me 
and that its contents are true to the best of my information, knowledge, and belief.

CERTIFICATE OF MAILING

Date

 

Approved, SCAO
Form FOC 13a, Rev. 3/21
MCL 552.511a
Page 1 of 1

Friend of the court/Authorized representative 

 

 

Distribute form to: 
Friend of the court 
Obligor 
Requesting party

STATE OF MICHIGANJUDICIAL CIRCUITCOUNTYCOMPLAINT AND NOTICE FOR HEALTH-CARE EXPENSE PAYMENTCASE NO. and JUDGECourt addressCourt telephone no.Plaintiff’s namevDefendant’s name