APPLICATION FOR CONTEMPT ORDER, INCOME WITHHOLDING, AND/OR OTHER RELIEF STATE OF CONNECTICUT SUPERIOR COURT CITWFRD www.jud.ct.gov JD-FM-15 Rev. 4-05 C.G.S. §§ 46b-215, 46b-220, 46b-231, 52-362 INSTRUCTIONS TO ATTORNEY OR PRO SE PARTY 1. Prepare original and two copies. 2. Obtain day of week for appearance from clerk. 3. Keep a copy for your files. 4. Forward original to the clerk. 5. After the clerk returns the signed original, forward to proper officer for service. Application is made to issue to the below-named Respondent a(n): COURT USE ONLY TO CLERK 1. Check all information for accuracy. 2. Sign the "Order" and "Summons" 3. Return original to preparer. TO SUPPORT ENFORCEMENT OFFICER 1. Complete "Application" and "Order and Summons." 2. Forward to proper officer for service. 3. Keep a copy for your files. 4. Return original to clerk after service. "X" ALL THAT APPLY INCOME WITHHOLDING CONTEMPT ORDER TO PROPER OFFICER See instructions on reverse/page 2. NAME OF CASE (Plaintiff vs. Defendant) DOCKET NO. JUDICIAL DISTRICT APPLICATION ORDER TO PARTICIPATE IN WORK ACTIVITIES PLAN TO PAY PASTDUE SUPPORT ADDRESS OF COURT (Number, street, and town) NAME OF PETITIONER (Applicant) ADDRESS OF PETITIONER (Number, street, and town) NAME OF RESPONDENT ADDRESS OF RESPONDENT (Number, street, and town) DATE JUDGMENT/AGREEMENT AMOUNT OF ORDER TOTAL BALANCE OWED DELINQUENCY $ $ $ HEALTH INSURANCE ORDERED AS OF (Date) CONTRIBUTIONS NOT MADE NOT MAINTAINED CHILD CARE NOT MADE AVAILABLE SIGNED (Petitioner or Support Enforcement Officer) I certify that the above information is true to the best of my knowledge and belief: UNREIMBURSED MEDICAL EXPENSES DATE SIGNED It is hereby ordered that the above-named respondent appear before the Superior Court/Family Support Magistrate Division at: ORDER AND SUMMONS ADDRESS OF SUPERIOR COURT/FAMILY SUPPORT MAGISTRATE DIVISION ON (Day of week) DATE (Mo., day, yr.) TIME (A.M./P.M.) to show cause why said respondent should not be held in contempt of court for failure to pay support and/or the child care or unreimbursed medical expense contributions and/or provide/maintain health insurance as ordered by the court or Family Support Magistrate, and/or to show cause why an income withholding, license suspension, and/or an order for a plan to pay any past-due support or an order to participate in work activities should not issue against said respondent. To: Any Proper Officer BY AUTHORITY OF THE STATE OF CONNECTICUT, you are hereby commanded to make service of this application and order on the above-named respondent according to law at least twelve (12) days, inclusive, before the court appearance "Date" indicated below. Hereof fail not but due service and return make. BY THE COURT/FAMILY SUPPORT MAGISTRATE DIVISION J. F.S.M SIGNED (Assistant Clerk, Support Enforcement Officer) NOTICE TO RESPONDENT DATE SIGNED (To be completed by proper officer) 1. You have been summoned to appear in court at: ADDRESS OF SUPERIOR COURT/FAMILY SUPPORT MAGISTRATE DIVISION ON (Day of week) DATE (Mo., day, yr.) TIME (A.M./P.M.) 2. If you fail to appear in court on the court appearance date and time shown above, a capias may be issued for your arrest and/or an income withholding may issue against your income. 3. The Superior Court and any Family Support Magistrate may issue an order to suspend the professional, occupational, recreational, commercial driver's and/or motor vehicle operator's license of a delinquent child support obligor and may order a plan for payment of any past-due support and/or participation in work activities. A "delinquent child support obligor" is (A) an obligor who owes overdue support, accruing after the entry of a court order, in an amount which exceeds ninety (90) days of periodic payments on a current support or arrearage payment order; (B) an obligor who has failed to make court ordered medical or dental insurance coverage available within ninety (90) days of the issuance of a court order or who fails to maintain such coverage pursuant to court order for a period of ninety (90) days; or (C) an obligor who has failed, after receiving appropriate notice, to comply with subpoenas or warrants relating to paternity or child support proceedings. ORDER (For use by Court/Family Support Magistrate Division only) in the The foregoing motion having been heard and it being found that the Respondent is in arrears as of (date) amount of $ it is hereby ORDERED: (order continues on reverse/page 2) BY THE COURT/FAMILY SUPPORT MAGISTRATE DIVISION J. SIGNED (Assistant Clerk) DATE OF ORDER F.S.M. (continued...) CONTEMPT ORDER/INCOME WITHHOLDING American LegalNet, Inc. www.FormsWorkflow.com (Continuation of Order) INSTRUCTIONS TO PROPER OFFICER 1. If applicable, fill in information required in the "Order and Summons" section and the "Notice to Respondent" section on front before making service. 2. Serve the copy on the respondent. 3. Complete the "Return of Service" section below and return. RETURN OF SERVICE Then and there by virtue of the original application, and by order of the Court/Family Support Magistrate Division, I served the Respondent with a true and attested copy of the original application, order and summons by (specify method of service) The within and foregoing is the original application, order and summons with my doings thereon endorsed. SIGNED (State Marshal, Support Enforcement Off., Proper Officer) PRINT NAME AND TITLE OF SIGNER DATE SERVED COPY ENDORSEMENT SERVICE TRAVEL TOTAL A TRUE AND ATTESTED COPY, ATTEST: (State Marshal or proper officer) JD-FM-15 (Back) Rev. 4-05 American LegalNet, Inc. www.FormsWorkflow.com