Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Court Division Name Of Plaintiff VERSUS ORDER REVOKING OBLIGOR'S LICENSING PRIVILEGES AND NOTICE TO AGENCY Name Of Defendant Name And Address Of Obligor MODIFICATION TO PAYMENT SCHEDULE Date Of Birth Race Sex G.S. 50-13.12; 110-142.2 The court makes the following findings of fact and conclusions of law based on the record and the evidence presented. FINDINGS AND CONCLUSIONS 1. This matter is before the court on a show cause order or motion to enforce the obligor's duty to pay child support as required by court order. The court has subject matter jurisdiction and personal jurisdiction over the obligor named above. The obligor received notice of the show cause order or motion and was was not present in court. 2. The obligor named above is required by a valid court order to pay child support in the amount shown below. As of the date of this hearing, the obligor is delinquent as shown below. Amount Of Current Support Obligation Weekly $ Monthly Biweekly Other (specify) Amount Of Delinquent Support $ Date Of Support Order (As Of at least one month's child support. 3. The obligor is willfully delinquent in child support payments equal to at least ninety (90) days' child support (IV-D cases only). (Additional findings of fact regarding willfulness may be entered below.) 4. The obligor currently holds the following licensing privileges: Type(s) Of License License Number(s) Hunting Fishing Trapping Name And Address Of Issuing Agency N. C. Wildlife Resources Commission, 1707 Mail Service Center, Raleigh, NC 27699-1707 N. C. Wildlife Resources Commission, 1707 Mail Service Center, Raleigh, NC 27699-1707 N. C. Wildlife Resources Commission, 1707 Mail Service Center, Raleigh, NC 27699-1707 Occupational, Business or Professional Occupational, Business or Professional Occupational, Business or Professional N. C. Division of Motor Vehicles, 1320 Mail Service Center, Raleigh, NC 27699-1320 N. C. Division of Motor Vehicles, 1320 Mail Service Center, Raleigh, NC 27699-1320 Driving Motor Vehicle Registration ( IV-D only) 5. Other: (Enter additional findings concerning obligor's eligibility for a limited driving privilege and any other relevant findings.) (Over) AOC-CV-650, Rev. 3/09 © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com ORDER It is ORDERED that: 1. The following licensing privileges of the obligor are hereby REVOKED until the obligor pays the "Amount Of Delinquent Support" shown on reverse, plus all further support coming due on and after the date of this Order. All licenses listed on front Trapping Hunting Fishing Driving Other (specify) 2. a. NOTE TO CLERK: If this option is checked, check "Modification To Payment Schedule" in title of form on front. The revocation of obligor's licensing privileges is STAYED on the following terms and conditions. First, that the obligor shall continue to pay current child support in the amount shown below. Second, that the obligor shall pay the full amount of the delinquency owed under said order by making additional payments as shown below and continuing until all delinquencies under said order are paid. Amount Of Current Support Obligation $ Additional Payment On Delinquency $ Weekly Monthly Bi-Weekly Total Amount Due (Beginning Date) $ Other (specify) b. The revocation of obligor's licensing privileges is NOT STAYED. The obligor is ordered to surrender any license revoked by this Order to the Clerk or IV-D agency immediately or within days. The obligor is not granted a limited driving privilege. The obligor is granted a limited driving privilege effective on the date of this Order subject to the following terms and conditions: Driving, other than for emergency medical care, is permitted only as follows: (1) For work-related purposes during standard work hours as follows: (2) Other: (specify) The Clerk or IV-D agency is directed to notify the appropriate licensing board or agency that the obligor is delinquent in child support payments and that the obligor's licensing privileges are revoked until such time as the licensing board receives proof of certification by the Clerk IV-D agency that the obligor is not delinquent in child support payments. Date Of Hearing Date Signed Name Of Presiding Judge (Type Or Print) Signature Of Presiding Judge CERTIFICATION I certify that this is a true copy of an original order on file in the office of the Clerk of Superior Court. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court NOTICE OF LICENSE REVOCATION YOU ARE REQUIRED to note the revocation of the obligor's licensing privileges upon the records of your board or agency and to take all steps necessary to implement and enforce the revocation of the obligor's licensing privileges. The Order Revoking Licensing Privileges is effective immediately and does not require your board or agency to institute an independent license revocation process pursuant to Chapter 20 or Chapter 150B of the General Statutes. This revocation shall remain in full force and effect until your board or agency receives certification from the Clerk or IV-D agency that the obligor is no longer delinquent in child support payments. Date Mailed To Licensing Board/Agency Signature Assistant CSC Clerk Of Superior Court Name And Address Of Licensing Board Or Agency Deputy CSC IV-D Agency Address Of Clerk Of Superior Court/IV-D Agency Telephone No. Of Clerk Of Superior Court/IV-D Agency NOTICE TO OBLIGOR: If the order revoking your licensing privileges has not been stayed, you may file a petition with the Clerk of Superior Court seeking reinstatement of your licensing privileges conditioned on your agreement to pay the current and delinquent child support that you owe. If the Court reinstates your licensing privileges or you pay all of the child support that you owe, you may obtain a certificate from the Clerk or IV-D agency allowing reinstatement of your licensing privileges. If the Court has granted you a limited driving privilege, you must keep a copy of this Order in your possession while you are driving a motor vehicle and comply with the conditions noted in the order. If you violate the conditions related to a limited driving privilege, you may be punished under G.S. 20-28(a) for driving while your license is revoked. IF YOUR DRIVERS LICENSE IS REVOKED FOR ANY OTHER REASON, THIS LIMITED DRIVING PRIVILEGE IS INVALID. AOC-CV-650, Side Two, Rev. 3/09, © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com