Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Superior Court Division Civil: NOTICE OF CHANGE OR TERMINATION OF WITHHOLDING FOR CHILD SUPPORT Plaintiff Criminal: STATE VERSUS Name Of Defendant G.S. 110-136.4, -136/5(e).-136.10; 15A-1344.1 Name And Address Of Employer Name And Address Of Obligor TO THE EMPLOYER NAMED ABOVE: CHANGE IN AMOUNT TO BE WITHHELD You are hereby notified that your existing obligation to withhold for child support from the disposable wages of the obligor (employee) named above is changed to $ per . The change is effective immediately (withhold new amount from next wages due) . All other provisions of your original Order/Notice To Withhold Income For Child Support in this case are unchanged and remain in effect. CHANGE IN MAXIMUM PERCENTAGE WHICH MAY BE WITHHELD You are hereby notified that the maximum percentage of disposable wages which may be withheld is changed from % to %. The change is effective immediately. . All other provisions of your original Order/Notice To Withhold Income For Child Support in this case are unchanged and remain in effect. TERMINATION You are hereby notified to stop withholding from the wages of the above named obligor (employee) pursuant to the Order/Notice To Withhold Income For Child Support issued in this case. This termination is effective immediately. . If you willfully refuse to comply with the requirements of this Notice, you may be held liable for any amount you should have withheld. Also, if a court finds you have discharged from employment, refused to employ, or have taken disciplinary action against an individual solely because of the withholding, you will be liable and a penalty or other legal sanctions will be imposed. Date Signature Deputy CSC (See Certificate and Return Of Service on reverse.) Assistant CSC Clerk Of Superior Court (NOTE: This Notice may be served on obligor (employee) by regular mail. Service on the employer may be made by certified mail. If certified mail is unsuccessful, this Notice must be served by the sheriff.) (NOTE: This form may be used in both civil and criminal cases.) Original - File AOC-CV-623, Rev. 3/09 © 2009 Administrative Office of the Courts Copy - Employer (Over) Copy - Employee American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE - OBLIGOR (EMPLOYEE) I certify that on the date listed below, a copy of this Notice was served on the obligor (employee) by regular mail. Date Mailed Signature Of Person Serving Notice Name (Type Or Print) Deputy CSC Assistant CSC Clerk Of Superior Court Other CERTIFICATE OF SERVICE - EMPLOYER I certify that on the date listed below, a copy of this Notice was served on the employer by certified mail, return receipt requested. Signature Of Person Serving Notice Date Mailed Name (Type Or Print) Deputy CSC Assistant CSC Clerk Of Superior Court Other RETURN OF SERVICE - EMPLOYER I certify that this Notice was received and served as follows: Date Served Name Of Employer By personally delivering the same to the employer named above. As the employer is a corporation or partnership, 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 Title Of Person With Whom Copies Left The employer WAS NOT served for the following reason: Date Received Signature Of Deputy Sheriff Making Return Date Of Return Name Of Sheriff (Type Or Print) County Of Sheriff AOC-CV-623, Page Two, Rev. 3/09 © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com