OUT OF WORK FORM Name ___________________________________________ Other Party(ies) Name ______________________________ ______________________________ ______________________________ Name of Company _________________________________ Date of layoff/termination (Circle One) _________________ Date of expected return to work _______________________ Date applied for unemployment _______________________ Amount of unemployment to be received per week $__________ Today's Date _______________ Account No. ________________ ________________ ________________ Is your support payment lower when you are out of work (Per your order)? Are you on a wage assignment? Yes No Yes No Will you be continuing to make your payments on a regular basis during your absence from work? If No, when will you be able to make your next payment? ___________________________ Yes No Other (Explain) ________________________________________________________________________________ When you return to work, please make an appointment with an enforcement officer. ____________________________________ Signature Please attach a copy of lay-off notice and unemployment benefit determination. American LegalNet, Inc. www.USCourtForms.com