Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice Superior Court Division District Plaintiff REQUEST FOR HEARING TO CONTEST WITHHOLDING TO ENFORCE CHILD SUPPORT VERSUS Defendant G.S. 110-136.4(a)(3) I request a hearing before the district court for the purpose of contesting the withholding from my disposable wages to enforce a child support obligation. In support of this request, I show the following: 1. The county named above is the county in which a support order has been entered, or is asserted by the IV-D Agency to have been entered, directing me to pay child support. 2. I received a Notice Of Intent To Withhold from the IV-D Agency on . 3. I contest the proposed withholding on the grounds of the following mistake of fact: (one or more blocks must be checked) I am not now, and was not at the time of the issuance of the Notice Of Intent To Withhold, in arrears in child support payments in an amount equal to the support payable for one month. The proposed withholding purports to be pursuant to my request for withholding, and I did not request that withholding begin. I am not the person who is subject to the court order of support for the child(ren) named in the Notice Of Intent To Withhold. I do not owe the amount of current support or arrearages specified in the Notice Of Intent Of Withhold or Motion To Withhold. Date Signature Of Person Requesting Hearing NOTE TO PERSON REQUESTING A HEARING: The original of this request is to be filed with the Clerk of Superior Court in the county where the original order was entered and a copy must be sent or delivered to the IV-D Agency that issued the Notice Of Intent To Withhold. AOC-CV-619, Rev. 3/09 © 2009 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com