Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Court Division Name Of Plaintiff MOTION AND ORDER TO SHOW CAUSE FOR FAILURE TO COMPLY WITH ORDER IN CHILD SUPPORT ACTION VERSUS Name Of Defendant G.S. 50-13.4; 5A-21 Name And Address Of Obligee Name And Address Of Obligor I, the undersigned, request the Court to issue an order requiring the obligor to appear and show cause, if any, why he/she should not be held in civil or criminal contempt for his/her failure to comply with the Court's order, and in support of the motion, present the following information: 1. The obligor has willfully failed to comply with an Order dated by a. failing to pay medical expenses in the amount of $ . b. failing to provide medical insurance for the child(ren). c. failing to provide obligee with a medical insurance card or information required to file a claim for the child(ren). d. failing to pay child support. The obligor owes $ as of (date). in past-due child support e. Other: 2. I am informed and believe that the obligor has the means to comply with the Court's order. Date SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Signature Of Person Authorized To Administer Oaths Date Deputy CSC Assistant CSC Signature Of Person Making Motion Nature of Interest In This Action Clerk Of Superior Court Plaintiff Date My Commission Expires Notary Defendant Other County Where Notarized SEAL ORDER TO APPEAR AND SHOW CAUSE TO THE PLAINTIFF DEFENDANT NAMED ABOVE: The Court finds probable cause to believe that you are in civil or criminal contempt for failing to comply with the Court's order as specified above. You are Ordered to appear at the date, time and place set out below to show cause, if any, why the Court should not enter an order holding you in civil or criminal contempt. Your failure to appear as ordered may result in the issuance of an Order For Arrest or your being jailed for civil contempt. Date Of Hearing Time Of Hearing Date Issued AM Place Of Hearing PM Signature Judge AOC-CV-601, Rev. 3/09 © 2009 Administrative Office of the Courts Assistant CSC Clerk Of Superior Court (Over) American LegalNet, Inc. www.FormsWorkflow.com RETURN OF SERVICE I certify that this Motion and Order was received and served as follows: Date Served Time Served Name Of Obligor AM PM delivering a copy personally to: Name Of Person With Whom Copy Left Name Of Person With Whom Copy Left depositing a copy in the United States mail in an envelope bearing proper postage and addressed as follows: Name And Address Name And Address leaving a copy at the office of the attorney named below, with a partner or employee Name Of Attorney Name Of Attorney Party Represented Party Represented Person With Whom Copies Left Person With Whom Copies Left By leaving a copy of this Motion and Order at the dwelling house or usual place of abode of the obligor named above with a person of suitable age and discretion residing therein. Name Of Person With Whom Copy Left Address Where Copy Delivered Or Left Date Accepted Signature Of Person Who Served Motion And Order Date Received Signature Of Deputy Sheriff Making Return Date Of Return Name Of Sheriff (Type Or Print) County Of Sheriff AOC-CV-601, Side Two, Rev. 3/09 © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com