Navigating the intricacies of child support and medical support can be challenging for both employers and individuals involved in the support process. Among the tools designed to manage these challenges is the Form 3F012, a critical document employed by the Texas Office of the Attorney General, specifically within the Medical Support Unit. This form serves as a medium for employers to report any changes in an employee's health insurance status or employment condition, as necessitated by the Texas Family Code sections 154.187 and 158.211. Each aspect of the form, from identifying the relevant parties involved, including the non-custodial and custodial parents, to outlining the procedure for notifying changes in employment or health insurance coverage, is structured to streamline the process of maintaining accurate and up-to-date support records. Instructions are also provided for how and where to return the completed form, emphasizing the need for timely communication, with specifics like the requirement for notification of withholding interruption within seven days, and insurance interruption within fifteen days of the event. The Form 3F012 embodies a comprehensive approach to managing changes that impact child support, guiding employers through the required steps to ensure compliance with state law and support affected families effectively.
| Question | Answer |
|---|---|
| Form Name | Form 3F012 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | child support application form, child support application, pdf texas child support appointment notice, child support texas application |
Office of the Attorney General
MEDICAL SUPPORT UNIT
P.O. BOX 1328
AUSTIN, TEXAS
FAX (855)
Bar Code Area (w/ FSN)
FS#:
GREG ABBOTT
Attorney General
Date:
Non- Custodial Parent: <F024> <F025> <F026>
Custodial Parent:
OAG Case Number:
Cause Number:
HEALTH INSURANCE STATUS CHANGE FORM
Employers are required to notify the Office of the Attorney General of a change of status of an employee [Texas Family Code, 154.187 and 158.211. Please keep this form for use as needed. If there is a change in the employee’s health insurance or employment status, please complete this form and return it to:
Medical Support Unit
P.O. Box 1328
Austin, TX
If you have any questions, please call (800)
Obligor:
Date of occurrence: ____________________________________Attorney General Case #.
This is to advise of a change in employment status between the above obligor and this employer.
[] The obligor is no longer employed by this employer; income withholding will stop on _______________________
(Notification of withholding interruption must be made within 7 days.)
The obligor’s last known home address: |
The obligor’s new employer name and address if known: |
_______________________________________ |
________________________________________________ |
_______________________________________ |
________________________________________________ |
Telephone Number: _______________________ |
________________________________________________ |
[ ] Health insurance coverage has lapsed.
Notification of insurance interruption must be within 15 days of occurrence.
If the obligor is eligible for health insurance conversion privileges (COBRA), please enclose information.
________________________________________ |
_______________________________ |
Signature of Person Completing Form |
Date Form Completed |
________________________________________ |
________________________________ |
Position / Title |
(Area Code) Telephone Number |
_______________________________________ |
|
Internet/Web Address |
|
April 2014 |
Form 3F012 |