JDF 1805 R 5 /1 8 NOTICE OF PENDING INCOME ASSIGNMENTPURSUANT TO 24714 - 14 - 111 - 5 (2)(a), C.R.S. Page 1 of 2 District Court Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co - Petitioner/Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom NOTICE OF PENDING INCOME ASSIGNMENT PURSUANT TO 24714 - 14 - 111 . 5 (2)(a), C.R.S. Notice is given that I, (Name of Obligee ) or my representative intend to activate an in come assignment if you, (Name of Obligor ), fail to make a full payment of child support and/or maintenance (spousal/partner support) , on the day the payment becomes due as ordered: If a full payment is not paid on the day it becomes due and an income assignment is activated, you have the right to file a written objection to the activation of the income assignment. Your objection must be based on a mistake of fact, such as an error in the identity of the Obligor or in the amount of support or arrears. If your objection is based on the amount of arrears, the income assignment may be activated and enforced as to current support obli gations, and the activation of the income assignment as to arrears will be stayed pending the outcome of a hearing on your objection. When there are arrears, the income assignment shall include payment on these arrears in the amount of one - twenty - fourth of the total amount due up to the date of activation, unless the Obligee or representative agrees to a different payment amount after activation. withhold income for payment of a support obligation and arrears. You may request that the income assignment be activated at any time. When the income assignment is activated, it shall be a continuing assignment that will apply to your present employer and any future employers. I f payments are made through the Family Support Registry, you must change employment. By checking this box, I am acknowledg ing I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. Date of Order Court Case Number Name of Court Amou nt of Payment Date(s) Payment Due Each Month American LegalNet, Inc. www.FormsWorkFlow.com J DF 1805 R 5 /1 8 NOTICE OF PENDING INCOME ASSIGNMENTPURSUANT TO §14 - 14 - 111 - 5 (2)(a), C.R.S. PAGE 2 OF 2 SIGNATURE (Printed name of Obligee) Date (Type/print Address) (Type/Print Home Number) (Work Number) CERTIFICATE OF SERVICE I certify that on (date): I had the Obligor PERSONALLY SERVED with the original Notice of Pending Income Assignment and filed the Return of Service with the Court. OR I sent the original Notice of Pending Income Assignment to the Obligor by - known address as follows and filed a copy with the C ourt. (Your signature)