Please fill in the fields below, then click on the "Print Form" button. Once printed, date, sign and submit the form to the Friend of Court office to begin enforcement action.
As of this date, the expense information in the attached Request for Health Care Expense Payment is true except as follows: Since the date I mailed the Request for Health Care Expense Payment to the obligor (Person from whom you are seeking reimbursement), the obligor PAID the amount of $ for
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