Form 217 Rev 5/16 The Family Court of the State of Delaware In and For New Castle Kent Sussex County APPEAL OF CHILD SUPPORT ADMINISTRATIVE DECISION AND ORDER DCSS # FILE # DOB PETITION # Other state # DOB Appellant Name v. Appellee Name Street Address (including Apt) Street Address (including Apt) P.O. Box Number City State Zip Code P.O. Box Number City State Zip Code Home Phone # Work Phone # Cell Phone # Attorney Name and Phone Number Home Phone # Work Phone # Cell Phone # Attorney Name and Phone Number Employer: Employer Address: Employer: Employer Address: Nature of Proceeding: License Suspension/Denial Administrative Lein Income Tax Offset Other: PLEASE TAKE NOTICE THAT does appeal to the Family Court of the State of Delaware from an administrative decision entered by dated which affirmed the above noted sanction(s). Reasons for the appeal are: The appellant is not the person named in the underlying child support order. The appellant does not owe the amount of child support arrears required for the sanction imposed Other: A COPY OF THE ADMINISTRATIVE DECISION MUST BE ATTACHED TO THE APPEAL APPELLANT AFFIRMS that the above statements are true and that a copy of this appeal was deposited in the U.S. mail on with sufficient postage and addressed to The Division of Child Support Services at P.O. Box 12831, Wilmington, DE 19850 and/or BY COPY OF THIS APPEAL, APPELLEE IS NOTIFIED OF THE RIGHT TO FILE A RESPONSE WITHIN TEN (10) DAYS OF THE FILING OF THIS APPEAL. Date SWORN TO AND SUBSCRIBED before me this date Appellant/ Attorney Date Clerk of Court/Notary Public AFTER HEARING UPON CONSIDERATION OF THE APPEAL AND: THE RECORD OF THE ADMINISTRATIVE HEARING NO RECORD OF ADMINISTRATIVE HEARING affirmed reversed. IT IS SO ORDERED. filed by DCSS, the administrative decision is ( See discussion attached) Judge/Commissioner Cc: File Parties DCSS Counsel DCSS Reciprocal Agency Date American LegalNet, Inc. www.FormsWorkFlow.com