Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Superior Court Division Civil: Plaintiff Criminal: MOTION TO WITHHOLD FROM STATE INCOME OTHER THAN WAGES TO VERSUS Name Of Defendant ENFORCE CHILD SUPPORT ORDER G.S. 110-136.5, -136.10Name And Address Of Payor Name And Address Of Obligor Federal Tax ID No. Social Security No. MOTION The obligor is a responsible parent of each child named below for whose benefit support is due. Pursuant to an Order entered by this Court for support of said child(ren), the obligor is obligated to pay child support in the amount shown below. As of the date of this Motion, the obligor is delinquent. has been erratic in making child support payments. Name Of Each Child For Whose Benefit Support Is Due Date Of Birth Amount Of Support Obligation Weekly Monthly Date Of Support Order Or Judgment $ Bi-weekly Other (specify) Amount Of Past Due Support $ As of (Date) The undersigned believes that the obligor receives disposable income from the payor named above as set out below: Amount Of Disposable Income Weekly Monthly Type Of Income $ Bi-weekly Other (specify) Now, therefore, the undersigned seeks to have the following amount withheld from the obligors income to satisfy the order as directed by the Court. Amount Sought To Be Withheld (NOTE: Amount withheld ordinarily may not exceed 40% of disposable income.) $ Therefore, the undersigned requests the Court to enforce the obligors child support obligation by entry of an order forDate Signature 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 Signature Of Person Authorized To Administer Oaths Name And Address Of Person Making Motion Deputy CSC Assistant CSC Clerk Of Superior Court Date My Commission Expires SEAL Notary AOC-CV-906M, Rev. 3/03 (See NOTICE TO OBLIGOR On Reverse) 2003 Administrative Office of the Courts >>>> 2 NOTICE TO OBLIGOR Take notice that the foregoing Motion asks the court to order withholding from your disposable income to enforce a child support obligation, and 1. If the court orders withholding, the order will apply to disposable income from your current payor(s) and from any 2. If income withholding is ordered, it will continue until a. the child support order being enforced has expired or becomes invalid; or b. the party initiating this proceeding, the district court judge, and you agree to terminate withholding because there is another adequate means to collect child support or arrearages; or c. all valid arrearages owed to the State or obligee are paid in full, and the whereabouts of each child for whom support is owed and the party entitled to receive the support payments are unknown. CERTIFICATE OF SERVICE I certify that a copy of this Motion was served by: depositing a copy enclosed in a postpaid properly addressed envelope in a post office or official depository under the exclusive care and custody of the U.S. Postal Service directed to: defendant. defendants attorney. plaintiff. plaintiffs attorney. delivering a copy personally to the: defendant. defendants attorney. plaintiff. plaintiffs attorney. 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 Other: Date Served Title Of Person Serving Motion Signature Of Person Serving Motion AOC-CV-906M, Side Two, Rev. 3/03 2003 Administrative Office of the Courts