IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT COUNTY, ILLINOIS IV-D No. Case No. Plaintiff/Petitioner Defendant/Respondent File Stamp PROOF OF SERVICE ORDER/NOTICE FOR INCOME WITHHOLDING Copies of the Order/Notice to Withhold Income for Child Support entered in the above case on has been delivered to (date) (Employer Name); or the said payor's superintendent, manager, or other agent; and (Obligor Name), obligor; by: Employer: Obligor: Employer address: Obligor address: Regular Mail Certified mail, return receipt requested By fax transmission to the following telephone number Regular Mail Certified mail, return receipt requested By fax transmission to the following telephone number and immediately thereafter telephoned and immediately thereafter telephoned , and spoke to who verified receipt of said fax transmission. Personal Delivery Other method provided by law for service of a summons (Specify) and spoke to who verified receipt of said fax transmission. Personal Delivery Other method provided by law for service of a summons (Specify) That service was made on That service was made on That I provided the payor with the name(s) and Birthdate(s) of the minor(s) for whom health insurance is required together with the obligee's address. CERTIFICATION Under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true. Obligee or Legal Representative By: Signature Address, City, State & Zip Home Phone No. Work Phone No. P1-CS-001 (11/07) American LegalNet, Inc. www.FormsWorkflow.com