Court File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County Name Of Plaintiff MOTION TO WITHHOLD WAGES TO ENFORCE CHILD SUPPORT ORDER VERSUS Name Of Defendant G.S. 110-136.5 Name, Mailing And Location Address Of Employer Name, Mailing And Location Address Of Obligor 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 the child(ren) named below 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 Child(ren) Name Of Child(ren) Date of Birth Amount Of Support Obligation Weekly Monthly $ Bi-weekly Date of Birth Other (specify) Date Of Support Order Amount Of Past Due Support $ As Of (Date) The undersigned believes that the Obligor receives disposable wages from the employer named above as set out below. Amount Of Disposable Wages Weekly Monthly $ Bi-weekly Other (specify) Now, therefore, the undersigned seeks to have the following amount withheld from the Obligor's wages to satisfy the Order as directed by the Court. Amount Sought To Be Withheld (NOTE: Amount withheld ordinarily may not exceed 40% of disposable wages.) $ Therefore, the undersigned requests the Court to enforce the Obligor's child support obligation by entry of an order for wage withholding. Signature Of Person Making Motion Date 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/AFFIRMED AND SUBSCRIBED TO BEFORE ME Signature Of Person Authorized to Administer Oaths Date Deputy CSC Assistant CSC Clerk Of Superior Court Signature Of Person Making Motion Name And Address Of Person Making Motion Date Commission Expires Notary County Where Notarized SEAL AOC-CV-616, Rev. 3/09 © 2009 Administrative Office of the Courts (See NOTICE OF OBLIGOR On Reverse) American LegalNet, Inc. www.FormsWorkflow.com NOTICE TO OBLIGOR Take Notice that the foregoing Motion asks the Court to order withholding from your wages to enforce a child support obligation, and: 1. If the Court orders withholding, the Order will apply to wages from your current employer and from any future employer. 2. If wage 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 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 I served a copy of this Motion by: 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 Date Of Service Signature Of Person Who Served Motion And Notice AOC-CV-616, Side Two, Rev. 3/09 © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com