THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF NON-COMPLIANCE V. Plaintiff Defendant Current Address I (We), plaintiff(s) in this matter, do hereby state that defendant(s) has (have) failed to comply with the Court's order for periodic payment dated , and request that the Court issue orders , of notice to show cause why the defendant(s) should not be held in contempt. Date of Last Payment: Total Amount Paid: Total Amount Due: $ $ I request that orders of notice be issued to me for service by certified mail, restricted delivery, return receipt requested. I understand that I will responsible for this expense. I request that orders of notice be issued to me for personal service by a law enforcement officer. I understand I will be responsible for this expense. I certify that on this date I provided a copy of this document to Defendant/Defendant Attorney by: Hand-delivery OR US Mail OR E-mail (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Plaintiff's Signature NHJB-2423-DP (03/25/2013) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com