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

Current through Register Vol. 54, No. 28, July 13, 2024
(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:
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 earnings information requested. Attach
				  a copy of the employe's most recent W-2 Form.
Payroll Number: ___
Nature of Employment:
						  _________________________
Payroll Period Ending
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Date of Pay
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Gross Pay
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Deductions
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Fed. Withholding
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Social Security
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Local Wage Tax
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State Income Tax
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Payroll Period Ending
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Date of Pay
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Gross Pay
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Deductions
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Fed. Withholding
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Social Security
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Local Wage Tax
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State Income Tax
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Retirement
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Savings Bonds
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Credit Union
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Life Insurance
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Health Insurance
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Other (Specify)
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Net Pay
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Hours Worked
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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
Type of Coverage
Full Name SS
						  #
Hospitalization
Medical
Dental
Eye
Prescription
Other
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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: ___________________