IN THE CIRCUIT/CHANCERY COURT OF SHELBY COUNTY TENNESSEE Plaintiff, ________________________________ Vs. DOCKET NO: __________________ Defendant,_______________________________ PETITION TO MODIFY SUPPORT ORDER AND/OR WAGE ASSIGNMENT (4 pages) Comes now the Petitioner, ______________________________, seeking to modify a prior support order as follows: Check (ü) one or more of the following options shown below. ü 1. ¨ To modify a previous support order as follows: (Be specific) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. ¨ To terminate wage assignment. (Give reason for request) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. ¨ To partially terminate wage assignment. (Give reason for request) If there are remaining minor children include date of birth and name. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. ¨ To consent to the following: (Be specific) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Form P0-07/04 1 American LegalNet, Inc. www.USCourtForms.com 5. ¨ Other support issues to modify: (Be specific) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ The above facts are true and correct to the best of my knowledge and belief. Petitioner’s Signature: _____________________________________________________ Address: _______________________________________________________________ Telephone Number: ______________________________________________________ State of Tennessee County of Shelby Sworn to and Subscribed before me on this ______day of __________________20____. __________________________________________ Notary Public or Deputy Clerk Respondent’s Signature ____________________________________________________ Address: _______________________________________________________________ Telephone Number: ______________________________________________________ State of Tennessee County of Shelby Sworn to and Subscribed before me on this ______day of __________________20____. __________________________________________ Notary Public or Deputy Clerk 2 American LegalNet, Inc. www.USCourtForms.com ________________________________________________________________________ FIAT ________________________________________________________________________ To the Clerk and Master of the Shelby County Chancery Court: Issue notice to the respondent that a hearing regarding the above petition will be heard in Part ____ of Chancery Court on the ____ day of __________, 20____ at ____: ____ ____. M. ____________________________________ JUDGE/CHANCELLOR ____________________________________ DATE REFERENCE TO DIVORCE REFEREE The above matter is referred to the Divorce Referee for a hearing regarding the above requested relief. This cause is set for Hearing on the _________day of __________________, 20______, at 1:00 p.m. at the following location: Shelby County Courthouse 140 Adams, Room 327 Memphis, TN 38103 Phone: 901-545-4036 ____________________________________ JUDGE/CHANCELLOR ____________________________________ DATE CERTIFICATE OF SERVICE certify that a copy of this Petition, with Hearing date included, was mailed to the Respondent at__________________________________ by United States Mail prepaid this __________day of __________________________, 20_____. I ___________________________________________ DEPUTY COURT CLERK 3 American LegalNet, Inc. www.USCourtForms.com IN THE CIRCUIT/CHANCERY COURT OF SHELBY COUNTY TENNESSEE Plaintiff, __________________________________ Vs. DOCKET NO. ________________ Defendant, ________________________________ ________________________________________________________________________ RECOMMENDATIONS OF DIVORCE REFEREE _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ ________________________ at the ____ plaintiff’s ____ defendant’s cost. ____________________________________ DIVORCE REFEREE ____________________________________ DATE ________________________________________________________________________ ORDER MODIFYING SUPPORT ORDER ________________________________________________________________________ The above recommendations of the Divorce Referee are confirmed and so ordered by the court. ____________________________________ JUDGE/CHANCELLOR ____________________________________ DATE Form: P0-09/04 4 American LegalNet, Inc. www.USCourtForms.com