CONTEMPT PROCEEDINGS UPON FAILURE OF PAYER OF INCOME TO COMPLY WITH WITHHOLDING ORDER FOR SUPPORT JD-FM-124 Rev. 1-15 C.G.S. §§ 46b-88, 46b-231, 52-362 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions to clerk 1. Check all information for accuracy. 2. Complete the "Order and Summons." 3. Return original to applicant. Docket number COURT USE ONLY Instructions to applicant 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 MCTMEMP *MCTMEMP* 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) Agent of payer of income Name of case Name of obligor Amount of income withholding Date withholding was served on payer of income Amount of unpaid withholding $ Application Name of Applicant or Support Enforcement Officer making application Address of Applicant (Number, street, and town) $ The payer of income has failed to follow the requirements of Section 46b-88 and/or Section 52-362 of the Connecticut General Statutes in implementing the income withholding order listed above by: Failing to withhold support payment(s) from employee's income Failing to remit withheld support payment(s) to the State Disbursement Unit within the time required by Section 52-362 Failing to enroll the employee and his or her child or children in an appropriate health insurance plan (according to Section 46b-88, the National Medical Support Notice) Therefore, it is requested that the payer of income be held in contempt of court for failing to follow the requirements of Section 52-362 in implementing the income withholding order listed above and be held liable for any amount of the payment(s) that were required by the income withholding order after the payer of income received service of the income withholding order that the payer of income failed or refused to pay over as directed in the income withholding order. I certify that the information given above is Signed (Applicant or Support Enforcement Officer) true to the best of my knowledge and belief. 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: Address of Superior Court/Family Support Magistrate Division On (Day of week) Date (Month, day, year) Time Order and Summons A.M. P.M. to show cause why the payer of income should not be held in contempt of court for failure to withhold the income of the above-named obligor according to the income withholding order listed above 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/or failure to enroll the employee and/or his or her child or children in an appropriate health insurance plan. TO: Any Proper Officer By Authority of the State of Connecticut, you are commanded to serve and make return of service of this application and order on the payer of income named above according to law at least twelve (12) days, inclusive, before the court appearance "Date" indicated above. By the Court Signed (Assistant Clerk) ,J. ,F.S.M. Date signed Notice To Payer Of Income 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 for income not withheld from the obligor's income according to the income withholding order listed above, and/or for income withheld but not paid over to the state disbursement unit, and/or failing to enroll the employee and/or his or her child or children in an appropriate health insurance plan as ordered by the Superior Court or Family Magistrate. (Page 1 of 2) FOR COURT USE ONLY FILE DATE American LegalNet, Inc. www.FormsWorkFlow.com Order The foregoing motion having been heard, it is hereby ordered: By the Court ,J. ,F.S.M. Signed (Assistant Clerk) Date signed 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 ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. JD-FM-124 Rev. 1-15 (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com