Form FL-478 "Request and Notice of Hearing Regarding Health Insurance Assignment" - California

What Is Form FL-478?

This is a legal form that was released by the California Superior Court - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2007;
  • The latest edition provided by the California Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FL-478 by clicking the link below or browse more documents and templates provided by the California Superior Court.

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Download Form FL-478 "Request and Notice of Hearing Regarding Health Insurance Assignment" - California

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FL-478
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
TELEPHONE NO.:
FAX NO. (Optional):
end of the form when finished.
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
REQUEST AND NOTICE OF HEARING REGARDING
HEALTH INSURANCE ASSIGNMENT
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:
a.
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.
b.
The health insurance premium plus the monthly payment in any earnings assignment order are more than half of
c.
my total net income each month from all sources.
The following children (name):
are emancipated.
d.
I was not notified at least 15 days before the date of filing of the application that a health insurance coverage
e.
assignment was being sought.
No order to maintain health insurance has been issued.
f.
Health insurance coverage is or will be provided for the children, but not through a parent's job-related coverage
g.
(explain):
The employer's choice of coverage is inappropriate (explain):
h.
i.
Other (specify):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF PERSON REQUESTING HEARING)
(SIGNATURE OF PERSON REQUESTING HEARING)
Page 1 of 2
Form Adopted for Mandatory Use
REQUEST AND NOTICE OF HEARING REGARDING
Family Code, §§ 3761, 3765, and 3773
Judicial Council of California
www.courtinfo.ca.gov
HEALTH INSURANCE ASSIGNMENT
FL-478 [New January 1, 2007]
(Family Law—Governmental—UIFSA)
FL-478
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
TELEPHONE NO.:
FAX NO. (Optional):
end of the form when finished.
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
REQUEST AND NOTICE OF HEARING REGARDING
HEALTH INSURANCE ASSIGNMENT
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:
a.
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.
b.
The health insurance premium plus the monthly payment in any earnings assignment order are more than half of
c.
my total net income each month from all sources.
The following children (name):
are emancipated.
d.
I was not notified at least 15 days before the date of filing of the application that a health insurance coverage
e.
assignment was being sought.
No order to maintain health insurance has been issued.
f.
Health insurance coverage is or will be provided for the children, but not through a parent's job-related coverage
g.
(explain):
The employer's choice of coverage is inappropriate (explain):
h.
i.
Other (specify):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF PERSON REQUESTING HEARING)
(SIGNATURE OF PERSON REQUESTING HEARING)
Page 1 of 2
Form Adopted for Mandatory Use
REQUEST AND NOTICE OF HEARING REGARDING
Family Code, §§ 3761, 3765, and 3773
Judicial Council of California
www.courtinfo.ca.gov
HEALTH INSURANCE ASSIGNMENT
FL-478 [New January 1, 2007]
(Family Law—Governmental—UIFSA)
FL-478
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
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.
CLERK’S CERTIFICATE OF MAILING
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):
Date:
, Deputy
Clerk, by
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)
Page 2 of 2
FL-478 [New January 1, 2007]
REQUEST AND NOTICE OF HEARING REGARDING
HEALTH INSURANCE ASSIGNMENT
(Family Law—Governmental—UIFSA)
For your protection and privacy, please press the Clear This Form
Save This Form
Print This Form
Clear This Form
button after you have printed the form.
Page of 2