Section 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:

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TO:

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TO:

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AND NOW, this

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day of

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, 20

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, since it appears that

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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:

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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
Date of Pay
Gross Pay
Deductions
Fed. Withholding
Social Security
Local Wage Tax
State Income Tax
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 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:

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…Signed

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by:

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Position:

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

Official 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.

(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:

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Employee’s Social Security #:

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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- ization	Medical	Dental	Eye	Prescrip- tion	Other

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):

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Group #:

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Plan #:

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Policy #:

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Effective coverage date:

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Type of coverage:

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Cost of coverage for dependents:

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Insurance company (provider):

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Group #:

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Plan #:

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Policy #:

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Effective coverage date:

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Type of coverage:

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Cost of coverage for dependents:

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Insurance company (provider):

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Group #:

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Plan #:

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Policy #:

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Effective coverage date:

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Type of coverage:

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Cost of coverage for dependents:

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Insurance company (provider):

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Group #:

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Plan #:

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Policy #:

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Effective coverage date:

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Type of coverage:

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Cost of coverage for dependents:

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

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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:

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Signature:

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Title:

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The provisions of this § 1910.28 amended March 23, 1987, effective July 1, 1987, 17 Pa.B. 1499; amended December 2, 1994, effective March 1, 1995, 25 Pa.B. 6263; amended May 31, 2000, effective July 1, 2000, 30 Pa.B. 3155; amended September 24, 2002, effective immediately, 32 Pa.B. 5044. Immediately preceding text appears at serial pages (290225) to (290226) and (267769).