(1) Person Filing: Street Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO (2) Petitioner: Case Number: DO ORDER OF ASSIGNMENT A.R.S. § 25-504 Respondent: (4) (5) (3) ATLAS Number: TO: Current and future employers or other payors of the obligor: Name: Social Security Number: You shall withhold court-ordered monthly payments as follows: Current Child Support: $ Current Spousal Maintenance: $ Child Support Arrearages/Interest: $ Spousal Maintenance Arrearages/Interest: $ Clearinghouse Handling Fee:* $ Total Amount Per Month:** $ 5.00 * The $5.00 Handling Fee is subject to change and pursuant to A.R.S. § 25-510 is set by the Director of the Department of Economic Security by Administrative Rule, R6-7-103. **No more than 50% of the employee’s disposable earnings may be taken to satisfy an order issued for support or spousal maintenance. A.R.S. § 33-1131 This Order of Assignment modifies any previously dated Orders of Assignment with the same case number as listed above. This Order of Assignment is effective immediately upon receipt by an employer or other payor, including self-employed persons, and continues until further order, or until a period of 90 continuous days from the last payment to the obligor (person ordered to make support payments). If you are again obligated to pay monies to the obligor within 90 days, you are bound by this Order of Assignment. Payment must be sent to the Clearinghouse within 2 business days after the obligor is paid. (6) This Order of Assignment terminates on the last day of unless it includes an arrearage payment, in which case, the total amount listed above shall continue to be withheld until further order. All payments shall be sent to: Support Payment Clearinghouse, P.O. Box 52107, Phoenix, AZ 850722107 The ATLAS number above and the employee’s name and social security number above must appear on the transmittal payment form or check. You shall not discharge or otherwise discipline the person named in this assignment because of service of this order of assignment. Date Revised June 2010 Judicial Officer or Clerk of the Superior Court Arizona Supreme Court American LegalNet, Inc. www.FormsWorkFlow.com