AFFIDAVIT OF NONCOMPLIANCE WITH LICENSE SUSPENSION ORDER JD-FM-154 Rev. 2-06 C.G.S. § 46b-220 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov INSTRUCTIONS TO PREPARER 1. Complete affidavit and file original and two copies with the clerk. 2. Provide the obligor with a file-stamped copy of the completed affidavit. NOTICE The obligor must comply with the conditions of the suspension order within thirty (30) days of the issuance of the order. If the obligor fails to comply within the thirty-day period, this affidavit must be filed with the Court or assistant clerk of the Family Support Magistrate Division within forty-five (45) days after the expiration of the thirty-day period. The suspension order shall be effective upon the filing of this affidavit. FOR THE JUDICIAL DISTRICT OF NAME OF CASE AT (Address of court) NAME OF OBLIGOR DOCKET NO. I, the undersigned, duly depose and state that: 1. On (date) following license(s) held by the obligor: , the Court or Family Support Magistrate ordered the suspension of the 2. The conditions to avoid license suspension were: 3. The conditions to avoid license suspension were not met within thirty days of the issuance of the license suspension order. I hereby certify that the foregoing statements are true to the best of my knowledge and belief. SIGNED (Affiant) SIGNED (Clerk, Notary, Comm. Sup. Ct.) DATE SIGNED DATE SIGNED Subscribed and sworn to before me: For Court Use Only FILE DATE DISTRIBUTION: ORIGINAL - Court COPY1 - IVD Agency/Obligee COPY2 - Obligor American LegalNet, Inc. www.FormsWorkflow.com