STATE OF MAINE SUPERIOR COURT __________________________, ss Docket No.___________________ DISTRICT COURT Location_____________________ Docket No.___________________ Plaintiff CONDITIONAL INCOME WITHHOLDING ORDER FOR SPOUSAL SUPPORT 19-A M.R.S.A. §954 v. Defendant This Conditional Order of Income Withholding is incorporated in, and is a part of, the (Divorce Judgment) (Order) of this court dated . IMPORTANT NOTICE TO : Withholding of your income may result if you fail to pay spousal support as ordered by the court. However, no withholding shall take place until the following conditions are met: a. You request the withholding of your income, or b. Your spousal support payments are in arrears in an amount equal to at least one month's support, and you are notified of the amount of the arrearage in writing. c. The obligee must give you written notice of the amount of the arrearages at least 20 days before serving a copy of this order on the payor of income. During the 20 day period you may dispute the amount of the arrearage by filing a motion in this court asking the court to determine the amount in arrears. At the same time you may ask the court for a stay (delay) of service of this order on the payor. The court may issue a stay of not more than 60 days. It is ORDERED that The payor of income to (name of obligor) from any source shall withhold from any amounts due the obligor, and shall pay to the Maine Department of Human Services, at least monthly, the sum of $ per , which is the obligor's current spousal support obligation, together with an additional sum to be applied toward any arrearage of spousal support owed by the obligor, notice of which has been served on the payor with a copy of this withholding order. However, the total amount withheld by the payor shall not be greater than the maximum allowed by 19-A M.R.S.A. §2356 and 15 U.S.C. §1673. shall not serve a copy of this withholding (name of obligee) order on any payor of income until the provisions of 19-A M.R.S.A. §954(1)(B) have been met. It is further ORDERED that this Order be incorporated in the docket by reference pursuant to M.R.Civ.P. 79(a). Date: Judge / Justice / Magistrate FM-136, Rev. 09/05 American LegalNet, Inc. www.USCourtForms.com