! District Court _________________________________________ County, Colorado Court Address: In Re: Petitioner: Respondent/Co-Petitioner: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: E-mail: FAX Number: Atty. Reg.#: Division Courtroom NOTICE OF PENDING INCOME ASSIGNMENT PURSUANT TO §14-14-111-5 (2)(a), C.R.S. Notice is given that I, the Obligee, or my representative intend to activate an income assignment if you, , the Obligor, fail to make a full payment of child support and/or maintenance, on the day the payment becomes due as ordered: Date of Order Court Case Number Name of Court Amount of Payment ________________________________ Date(s) Payment Due Each Month 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 obligations, 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-twentyfourth of the total amount due up to the date of activation, unless the Obligee or representative agrees to a different payment amount after activation. The “activation” of an income assignment is when your employer, trustee, or other payor of funds is notified to 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. IF PAYMENTS ARE MADE THROUGH THE FAMILY SUPPORT REGISTRY, YOU MUST NOTIFY THE REGISTRY, IN WRITING, WITHIN 10 DAYS OF ANY CHANGE IN YOUR ADDRESS, YOUR EMPLOYER’S ADDRESS, OR IF YOU CHANGE EMPLOYMENT. Date: Obligee’s Signature (Type/Print Name) (Type/print Address) (Type/Print Home Number) JDF 1805 R9/00 (Work Number) NOTICE OF PENDING INCOME ASSIGNMENTPURSUANT TO §14-14-111-5 (2)(a), C.R.S. 2002 © American LegalNet, Inc. CERTIFICAT E 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 CERTIFIED MAIL to the Obligor’s last-known address as follows and filed a copy with the Court. (Your signature) JDF 1805 R9/00 NOTICE OF PENDING INCOME ASSIGNMENTPURSUANT TO §14-14-111-5 (2)(a), C.R.S. PAGE 2 OF 2 2002 © American LegalNet, Inc.