MOTION AND NOTICE OF PROPOSED INCOME DEDUCTION ORDER FOR SUPPORT Commonwealth of Virginia Case No. ...................................................................... DCSE ID No. ............................................................ VA. CODE § 20-79.1 ................................................................................................................................................................... Juvenile and Domestic Relations District Court ................................................................................................................................................................................................................................................................... ADDRESS v. ........................................................................................................................... ..................................................................................................................... PETITIONER RESPONDENT ........................................................................................................................... ..................................................................................................................... SOCIAL SECURITY NUMBER ADDRESS ..................................................................................................................... MOTION: I request the court to enter an income deduction order which contains the following terms: 1. Proposed Income Deduction Terms: Pay interval: [ [ [ [ [ ..................................................................................................................... SOCIAL SECURITY NUMBER ] weekly ............................................................................................... ] bi-weekly ......................................................................................... ] semi-monthly ................................................................................. ] monthly ............................................................................................ ] ................................................................................................................ regular pay dates OTHER PAY INTERVAL AND REGULAR PAY DATES The Respondent has also been ordered to provide health care coverage for the following persons: STATUS (check applicable box) NAME Dependent Child Current Spouse Former Spouse Payment Priority [ ] Support [ ] Health care coverage 1. ......................................................................................... 2. ......................................................................................... 3. ......................................................................................... 4. ......................................................................................... 5. ......................................................................................... 6. ......................................................................................... 2. Proposed amount to be deducted each pay period: $ ........................................... or ......................................... % of disposable income, whichever is less based on court-ordered payments of $ 3. ........................................ per ................................... with $ ....................................... total unpaid payments. Reason for proposed support income deduction order: [ ] receipt of notice of arrearage in support payments [ ] court has found that there is an arrearage of an amount equal [ ] facts relevant in determining the likelihood of [ ] request of the obligor [ ] Other: ............................................................................................................. to one month’s support obligation payments in accordance with the support order 4. .......................................................................................................................................................................................................................................................... EMPLOYER’S NAME .......................................................................................................................................................................................................................................................... EMPLOYER’S ADDRESS .............................................................................. __________________________________________________________________ DATE PETITIONER NOTICE TO THE RESPONDENT/OBLIGOR: Read this entire Notice (pages one and two) carefully. This motion is made pursuant to Virginia Code § 20-79.1. If you wish to contest this Motion, written notice must be filed in the clerk’s office by .................................................................................................................................... for a hearing on ........................................................................................... FILING DEADLINE ....................................................................................... DATE FORM DC-617 (MASTER, PAGE ONE OF TWO) 12/98 PC HEARING DATE ___________________________________________________________________________ [ ] CLERK [ ] DEPUTY CLERK American LegalNet, Inc. www.FormsWorkflow.com TO THE RESPONDENT/OBLIGOR: This notice is to advise you that this Court has been requested for the reason stated above to enter an order requiring all of your present and future employers to deduct support payments as described above from your income. This deduction will begin with the next regular pay interval for your income after your employers are served with an order. You have ten (10) days from the date of issuance of this Notice to file in the clerk’s office of this court a written notice of contest of such proposed order. If no written notice of contest is filed, the court will enter such an order at the end of the ten (10) day filing period. If you file a written notice of contest, — a hearing will be held and a decision made regarding the issuance of the Order and its contents within ten (10) days from the date that the Court receives your written notice of contest, unless good cause is shown for additional time, but not to exceed forty-five (45) days from your receipt of this notice, and — only disputes as to mistakes of fact (error in the identity of the payor or the amount of current support or arrearage) will be heard. Alleged inability to pay is not a grounds for contest. — payment of overdue support upon receipt of the notice shall not be the sole basis for not implementing withholding. The order will state that the deduction will start with the regular pay period for your income after you employer is served with an order. Your employer will be told the names of the petitioner, the court file number, the DCSE ID number (if any), your name, address, and social security number, and the terms of the periodic support payment, and where to send payments. The employer will also be told: — the maximum amount which can be withheld from your income, — that the order is binding on the employer until further notice sent by the court is received by the employer, — that the order requires income deductions for support to be paid before any other liens created under state law except that, when judicial or administrative income deduction orders for support have been previously served on the employer, the employer must prorate the amount withheld from your check among all income deduction orders of support based upon the current amounts due, with any remaining income prorated among the orders for accrued arrearages, if any, — that deductions are to be made on your regular payday and sent that date to the Virginia Department of Social Services and how to send such payments, — of his liability for failing to honor the order or for taking retaliatory action against you because of such order, — that the employer and respondent must notify the Virginia Department of Social Services when your employment terminates, and give your home address and the name and address of your new employer, — that the employer may deduct an additional fee of $5.00 for each time that the employer deducts money or answers in writing that the employer was legally unable to makes such deductions, — how the employer should respond if the order contains erroneous information, and — the statutory authorization for such order. SERVICE OF PROCESS ON RESPONDENT: [ ] Personal service Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode or party named above after giving information of its purport. (List name, age of recipient and relation to party named above.) ........................................................................................................................................................................................................................................................... [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) [ ] Certified mail. [ ] Facsimile service on employer to deliver to respondent. [ ] Not found. ................................................ DATE _____________________________________________ SERVING OFFICER FORM DC-617 (MASTER, PAGE TWO OF TWO) 4/06 for ____________________________________________