Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Superior Court Division Civil: MOTION TO JOIN PAYOR AS PARTY TO Plaintiff Criminal: STATE ENFORCE WITHHOLDING FROM INCOME VERSUS OTHER THAN WAGES AND Name Of Defendant NOTICE OF HEARING G.S. 110-136.8Name And Address Of Payor Name And Address Of Obligor Federal Tax ID No. Social Security No. MOTION In support of this Motion by the initiating party identified below the undersigned shows the Court that: 1. The disposable income of the obligor named above is subject to income withholding for child support pursuant to an order entered under G.S. 110-136.5 or to an administrative determination made pursuant to G.S. 110-136.4. 2. Pursuant to that order or determination, the payor named above was properly served with a Notice Of Obligation To Withhold From Income Other Than Wages For Child Support. 3. The payor has willfully refused to comply with the provisions of G.S. 110-136.8 in that the employer/payor: a. did not begin withholding within the time provided by law, as stated in the Notice. b. has failed, on one or more occasions, to withhold and send to the North Carolina Child Support Centralized Collection Office, PO Box 900012, Raleigh, NC, 27675 the amount, or the percentage of disposable income, stated in the Notice. c. has failed, on one or more occasions, after withholding an amount from disposable income, to send that amount to the North Carolina Child Support Centralized Collection Office, PO Box 900012, Raleigh, NC, 27675 within the time provided by law as stated in the Notice. d. Other: Therefore the initiating party requests the Court to: 1. Cause the payor named above to be joined as a party to this action; 2. Order the payor to begin withholding pursuant to the terms of the Notice Of Obligation To Withhold From Income Other Than Wages For Child Support or as may be determined by the Court on the evidence presented; 3. Hold the payor liable for any amount which the payor should have withheld; and 4 . Tax the costs against the payor. Date Signature Identity Of Initiating Party Identity Of Signer Plaintiff Defendant State Clerk Of Superior Court Initiating Party Deputy CSC Assistant CSC IV-D Agency Attorney For Party Authorized Agent Other VERIFICATION I, the undersigned being first duly sworn, say that I have read this Motion and the contents are true to my own knowledge, except as to matters stated on information and belief, and as to those, I believe them to be true. Date SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Of Person Authorized To Administer Oaths Signature Deputy CSC Assistant CSC Clerk Of Superior Court SEE NOTICE OF HEARING ON REVERSE. Date My Commission Expires SEAL Notary (NOTE: This form may be used in both civil and criminal cases.) (Over) AOC-CV-910M, Rev. 3/03 2003 Administrative Office of the Courts >>>> 2 NOTICE OF HEARING TO THE EMPLOYER/PAYOR: You are notified to appear before the Court at the date, time and place of hearing stated below and to present any defense you have against the relief requested in the foregoing Motion. You may file a written response to the Motion in the office of the Clerk of Superior Court, and serve a copy on the initiating party within thirty (30) days of the date of service of this Motion. At the hearing, if the Court finds that you have willfully refused to comply with the provisions of G.S. 110-136.8, it may grant any or all of the relief requested in the Motion. Date Of Hearing Time Of Hearing Date AM PM Place Of Hearing Signature Deputy CSC Assistant CSC CSC Plaintiff/Attorney Defendant/Attorney Other RETURN OF SERVICE I certify that this Motion and Notice was received and served as follows: Date Served Time Served Name Of Employer/Payor AM PM By delivering to the payor named above a copy of this Motion and Notice. By leaving a copy of this Motion and Notice at the dwelling house or usual place of abode of the payor named above with a person of suitable age and discretion then residing therein. As the payor is a corporation, service was effected by delivering a copy of this Motion and Notice to the person named below. Name And Address Of Person With Whom Copies Left (If Corporation, Give Title Of Person Copies Left With) Other manner of service: (specify) Payor WAS NOT served for the following reason: Service Fee Paid Signature Of Deputy Sheriff Making Return Date Received$ Name Of Sheriff Date Of Return County Of Sheriff AOC-CV-910M, Side Two, Rev. 3/03 2003 Administrative Office of the Courts