PETITION FOR SUSPENSION OF PROFESSIONAL OR OTHER LICENSE CASE NO. Commonwealth of Virginia VA. CODE 63.2-1937 Circuit Court Juvenile and Domestic Relations District Court- V. PETITIONER RESPONDENT/OBLIGOR ADDRESS/LOCATION ADDRESS/LOCATION Social Security No. Social Security No. Telephone No. (H) (W) Telephone No. (H) (W) Date of Birth Date of Birth LICENSING AGENCY ADDRESS OF LICENSING AGENCY I, the undersigned petitioner, state under oath to the best of my knowle dge that the above named obligor isdelinquentin the payment of child support by a period of ninety days or more or fo r $5,000 or more, or has failed to comply with a subpoena,summons or warrant relating to paternity or child support proceedings. Delinquency: days. Alleged amount of delinquency: $ I have forwarded the notice required in Va. Code 63.2-1937. A copy of the certified mail certificate with proof of actualreceipt is attached. A copy of the notice is also attached. I request that the court suspend the obligors license, certificate, reg istration or other authorization to engage in a business,trade, profession or occupation or recreational activity issued by the C ommonwealth. TYPE OF LICENSE, CERTIFICATE, REGISTRATION OR OTHER AUTHORIZATION NAME OF LICENSE HOLDER AS IT APPEARS ON THE LICENSE LICENSE NUMBER DATE PETITIONERS SIGNATURE Sworn before me this day on DATE My commission expires on NOTARY SIGNATURE OF NOTARY PUBLIC INTAKE OFFICER FORM DC-670 PDF 10/02 American LegalNet, Inc. www.USCourtForms.com