For Clerk’s Use Only Name of Person Filing: ______________________________________ Mailing Address: ______________________________________ City, State, Zip Code: ______________________________________ Daytime Phone Number: ______________________________________ (4) ATLAS Number (if applicable): ___________________________________ Self Without Attorney or Representing: Attorney for: Petitioner Respondent THE SUPERIOR COURT OF ARIZONA MOHAVE COUNTY (1) Petitioner/Plaintiff (3) Case Number:__________________ AND ORDER OF ASSIGNMENT (2) Respondent/Defendant TO: Current and future employers or other payors of: (5)Name: SSN: (* Social Security # can be omitted if using the Confidential Sensitive Data Form) This order modifies and replaces any previous “Order of Assignment” with the same case number. You shall withhold court-ordered payments as follows: Current Child Support $_________________________ Current Spousal Maintenance/Support $_________________________ Payments on Arrears / Interest $_________________________ Clearinghouse Handling Fee $ 5.00 per month* TOTAL AMOUNT per month $ , but no more than 50% of disposable earnings (A.R.S. § 33-1131). *The Clearinghouse handling fee is set by statute and subject to change (A.R.S. § 25-510). 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. If you are again obligated to pay monies to the Obligor within 90 days, you are again bound by this “Order of Assignment.” Payment must be sent to the Support Payment Clearinghouse within two (2) business days of the date the monies were withheld. 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. You shall NOT discharge or otherwise discipline the person named in this assignment, because of service of this “Order of Assignment.” The above ATLAS number and employee's name must appear on the Transmittal Form or check. Make payments payable and send to: Support Payment Clearinghouse, P.O. Box 52107, Phoenix, AZ 85072-2107 DATED: ________________________ VIRLYNN TINNELL, CLERK OF SUPERIOR COURT By:_________________________ Deputy Clerk Revised 11/8/2010 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com