STATE OF CONNECTICUT SUPERIOR COURT CONTEMPT PROCEEDINGS UPON FAILURE OF PAYER OF INCOME TO COMPLY WITH WITHHOLDING ORDER FOR SUPPORT COURT USE ONLY MCTMEMP www.jud.ct.gov JD-FM-124 Rev. 11-01 C.G.S. § 46b-231, 52-362 INSTRUCTIONS TO PREPARER INSTRUCTIONS TO CLERK 1. Prepare original and 2 copies. 2. Obtain day of week for appearance from clerk. 3. Keep a copy for your files. 4. Forward original and 1 copy to clerk. JUDICIAL DISTRICT OF 1. Check all information for accuracy. 2. Complete the "Order" and "Summons". 3. Return original to preparer. INSTRUCTIONS TO PROPER OFFICER 1. Serve a copy on the Payer of income or its responsible agent and make return on the original. DOCKET NO. ADDRESS OF COURT (Number, street and town) Application is hereby made to issue a CONTEMPT ORDER against: NAME OF PAYER OF INCOME ADDRESS OF PAYER OF INCOME (Number, street and town) APPLICATION NAME OF CASE AGENT OF PAYER OF INCOME NAME OF OBLIGOR AMOUNT OF INCOME WITHHOLDING DATE WITHHOLDING WAS SERVED ON PAYER OF INCOME AMOUNT OF UNPAID WITHHOLDING $ $ NAME OF PETITIONER (Applicant) ADDRESS OF PETITIONER (Number, street and town) The payer of income has failed to comply with the requirements of C.G.S. § 52-362 in implementing said income withholding. WHEREFORE it is requested that the payer of income be held in contempt of court for failing to comply with the requirements of C.G.S. § 52-362 in implementing the aforementioned income withholding and be held liable for any amount of said payments to be enforced by income withholding after service of said income withholding that the payer of income failed or refused to pay over as directed by said income withholding. I certify that the above information is true to the best of my knowledge and belief. SIGNED (Petitioner or Support Enforcement Officer) DATE SIGNED It is hereby ordered that the above-named payer of income or its responsible agent appear before the Superior Court/Family Magistrate Division at: ORDER AND SUMMONS ADDRESS OF SUPERIOR COURT/FAMILY SUPPORT MAGISTRATE DIVISION ON (Day of week) DATE (Mo., day, yr.) TIME . M. to show cause why said payer of income should not be held in contempt of court for failure to withhold the income of the above-named obligor pursuant to the aforementioned income withholding and/or failure to make payments to the petitioner or the state disbursement unit as ordered by the Superior Court or Family Support Magistrate and why the other prayers in the application should not be granted. 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 payer of income by leaving a true and attested copy of this application and order with and in the hands of said payer of income or its responsible agent at least twelve (12) days, inclusive, before the court appearance "Date" indicated above. Hereof fail not but due service and return make. BY THE COURT ,J. SIGNED (Assistant Clerk) DATE SIGNED ,F.S.M. NOTICE TO PAYER OF INCOME FOR COURT USE ONLY FILE DATE 1. This paper summons you to appear in court at the address and on the day, date, and time noted above. 2. If you fail to appear in court on the Court Appearance Date and Time a capias may be issued for your arrest. In addition, you may be found in contempt and be held liable to the petitioner for income not withheld from the obligor's income pursuant to the aforementioned income withholding and/or for income withheld but not paid over to the petitioner or the state disbursement unit as ordered by the Superior Court or Family Support Magistrate. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com ORDER The foregoing motion having been heard, it is hereby ordered: BY THE COURT ,J. SIGNED (Assistant Clerk) DATE SIGNED ,F.S.M. RETURN OF SERVICE STATE OF CONNECTICUT, COUNTY OF NAME OF PAYER OF INCOME OR AGENT SERVED DATE OF SERVICE ss. NAME OF PERSON SERVED Then and there, by virtue of the original application, and by order and summons of the court, I left a true and attested copy thereof with and in the hands of the above-named payer of income or its responsible agent. The within and foregoing is a true copy of the original application, order and summons with my doings thereon endorsed. ATTEST (State Marshal, Support Enforcement Officer, Proper Officer) TITLE OF SIGNER FEES COPY ENDORSEMENT SERVICE TRAVEL TOTAL JD-FM-124 (back/page 2 of 2) Rev. 11-01 American LegalNet, Inc. www.FormsWorkflow.com