For Clerk’s Use Only Name of Person Filing: _____________________________________ Mailing Address: _____________________________________ City, State, and Zip Code: _____________________________________ Daytime Phone Number: _____________________________________ Evening Phone Number: _____________________________________ ATLAS Number (if applicable: _____________________________________ State Bar Number (if applicable): ___________________________________ Representing: Self Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: (Name of Petitioner) REQUEST FOR RELEASE FROM ORDER OF ASSIGNMENT Employer / Payor AND (Name of Respondent) On ____________________________________________, this Court ordered an Assignment of the earnings (Date) or entitlements of ________________________________________________________________________. (Obligor) I am Obligor’s employer / payor and allege that support payments submitted to the Support Payment Clearinghouse for the person named above have been returned to me. WHEREFORE, I request an Order releasing the employer / payor from the binding effect of the above-referenced Order of Assignment. I have read the foregoing document and the facts therein are true and correct to the best of my knowledge. I will immediately mail or deliver a copy of the Request to the Obligor. Date:________________________ STATE OF ARIZONA COUNTY OF MOHAVE _______________________________________ Employer / Payor ) )ss. ) SUBSCRIBED AND SWORN OR AFFIRMED AND ACKNOWLEDGED before me this _______________ day of _______________________, ___________ by ___________________________________ VIRLYNN TINNELL CLERK OF SUPERIOR COURT My Commission Expires: _________________ ______________________________ Notary Public / Deputy Clerk 6/11/2008 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com