Circuit Court for Name Address City or County Case No. vs. Name Address City, State, Zip City, State, Zip Telephone Telephone Plaintiff Defendant PETITION FOR CONTEMPT (Failure to Pay Child Support) (CC-DR-002) I, 1. I am the My name , representing myself, state that: Relationship (for example, aunt, grandfather, guardian, etc.) mother/ Check One father or of the following minor child(ren) or adult disabled child(ren): Name of Child Name of Child Name of Child Date of Birth Date of Birth Date of Birth Name of Child Name of Child Name of Child Date of Birth Date of Birth Date of Birth 2. On Date the Circuit Court for City or County issued an Name order in case number to pay $ 3. Name Amount , ordering weekly/ (Check One) biweekly monthly toward the support of the child(ren). has not made child support payments as required by the Order. child support is due as of . 4. 5. I Amount Date do/ (Check One) do not want the court to order jail time to enforce its order. FOR THESE REASONS, I request the Court issue a Show Cause Order, issue an Order of Contempt for failure to pay child support, order payment of current child support and arrearages, and order other appropriate relief. Date Signature CC-DR-002 (Rev. 08/2016) American LegalNet, Inc. www.FormsWorkFlow.com