§ Rule 1910.28 Order for Earnings and Health Insurance Information Form of Earnings Report Form of Health Insurance Coverage Information

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: ____________________

AND NOW, this __________ day of __________, 20____, since it appears that ______(Name of employee is employed by you, and it is necessary 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:

______________________________________

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

Employer: ________________________ Re: Name ________________________________________

________________________ Social Security

No.________________________________________

Support Action No.

________________________________________

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 earningsinformation requested. Attach a copy of the employee's most recent W-2 Form.

Payroll Number: _________________________________________________

Nature of Employment: _________________________________________________

Payroll Period Ending ________ ________ ________ ________ ________

Date of Pay ________ ________ ________ ________ ________

Gross Pay ________ ________ ________ ________ ________

Deductions ________ ________ ________ ________ ________

Fed. Withholding ________ ________ ________ ________ ________

Social Security ________ ________ ________ ________ ________

Local Wage Tax ________ ________ ________ ________ ________

State Income Tax ________ ________ ________ ________ ________

Retirement ________ ________ ________ ________ ________

Savings Bonds ________ ________ ________ ________ ________

Credit Union ________ ________ ________ ________ ________

Life Insurance ________ ________ ________ ________ _ _______

Health Insurance ________ ________ ________ ________ ________

Other (Specify) ________ ________ ________ ________ ________

_______________________________ ________ ________ ________ ________ ________

Net Pay ________ ________ ________ ________ ________

Hours Worked ________ ________ ________ ________ ________

I verify that the statements made in this Earnings 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: _________________________________________________

Note: The information requested in the following report may be provided by an employer on its own form, for example, as a computer print out.

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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.

Type of Coverage

Full Name SS # Hospital- Medical Dental Eye Prescrip- Other
ization tion

______________________________ [ ] [ ] [ ] [ ] [ ] [ ]

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: ______________________________________