Pennsylvania Code
Title 231 - RULES OF CIVIL PROCEDURE
Part I - GENERAL
Chapter 1910 - ACTIONS FOR SUPPORT
Rule 1910.28 - Order for Earnings and Health Insurance Information. Form of Earnings Report. Form of Health Insurance Coverage Information

(a) The order for earnings and health insurance information shall be in substantially the following form:

(Caption)

ORDER FOR EARNINGS REPORT, HEALTH

INSURANCE INFORMATION AND SUBPOENA

TO: ____________

TO: ____________

TO: ____________

AND NOW, this ____________ day of ____________ ,. ___ , since it appears that ____________ is employed by you, and it is necessary

Name of employee

that the Court obtain earnings and health insurance information relating to the above-named individual in order to adjudicate a matter of support, IT IS HEREBY ORDERED AND DECREED that you supply the Court with the information required by the enclosed Earnings Report and Health Insurance Coverage Report and file them with the Court within fifteen (15) days of the date of this order.

If you fail to supply the information required by this Order, a subpoena will issue requiring you to attend Court and bring the material with you, or other appropriate sanctions will be imposed by the Court.

BY THE COURT: ______________________________________

J.

(b) The employer shall file an Earnings Report substantially in the following form:

EARNINGS REPORT

To the Employer:

Furnish earnings information for the above-named employee for each pay period during the last six months. It is preferred that you attach a photocopy of your records containing the earnings information requested. Attach a copy of the employe's most recent W-2 Form.

I verify that the statements made in this Earning Report are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

Date: ___

Signed _________________________

by: ____________

Position: ______________________________________

(c) The form which the employer uses to report health insurance coverage information shall be substantially as follows:

(Caption)

HEALTH INSURANCE COVERAGE REPORT

This information must be completed and returned within 15 days. Failure to comply may result in issuance of a subpoena or other appropriate sanctions.

Employee's Name: _________________________

Employee's Social Security #: _________________________

Does the employer make medical, dental, eye care, prescription or other insurance coverage available to the employee? Yes [] No []

Name the dependents covered under the employee's insurance, and indicate which types of coverage they have through your company

Provide the information indicated for each type of insurance which is available to the employee, whether or not any of the above-named dependents are covered at this time:

Insurance company (provider): ____________________

Group #:_____ Plan #:_____ Policy #:________________

Effective coverage date: _____ Type of coverage: ____________________

Cost of coverage for dependents: ____________________

Insurance company (provider):______________

Group #: ______ Plan #: _____ Policy #: ________________

Effective coverage date: __________ Type of coverage: ________________

Cost of coverage for dependents: _____________

Insurance company (provider): ________________

Group #: ____ Plan #: _____ Policy #: ________

Effective coverage date: __________ Type of coverage: ___________

Cost of coverage for dependents: __________ Insurance company (provider): _________________

Group #: ____ Plan #: _____ Policy #: ______________

Effective coverage date: ______ Type of coverage: ________

Cost of coverage for dependents: _______________

If the above-named dependents are not currently covered by insurance, please state the earliest date coverage could be provided.

PLEASE PROVIDE FORMS NECESSARY TO

ADD DEPENDENTS, AS THE EMPLOYEE MAY

BE ORDERED TO PROVIDE COVERAGE FOR THEM.

I verify that the statements made in this Health Insurance Coverage information form are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

Date: ____________________

Signature: ___________________

Title: ___________________