Fill and Sign the Application for Contempt Order Income Withholding Andor Other Relief Form

DATE SIGNED TO PROPER OFFICER See instructions on reverse/page 2. TO ATTORNEY OR PRO SE PARTY 1. Prepare original and two copies. 2. Obtain day of week for appearance from clerk. 3. Keep a copy for your files. 4. Forward original to the clerk. 5. After the clerk returns the signed original, forwardto proper officer for service. APPLICATION FOR CONTEMPT ORDER, INCOME WITHHOLDING, AND/OR OTHER RELIEF STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov JD-FM-15 Rev. 4-05 C.G.S. §§ 46b-215, 46b-220, 46b-231, 52-362 NOTICE TO RESPONDENT (To be completed by proper officer) NAME OF RESPONDENT NAME OF CASE (Plaintiff vs. Defendant) TO CLERK 1. Check all information for accuracy. 2. Sign the "Order" and "Summons" 3. Return original to preparer. TO SUPPORT ENFORCEMENT OFFICER 1. Complete "Application" and "Order and Summons." 2. Forward to proper officer for service. 3. Keep a copy for your files. 4. Return original to clerk after service. APPLICATION Application is made to issue to the below-named Respondent a(n): DOCKET NO. NAME OF PETITIONER (Applicant) JUDICIAL DISTRICT DATE JUDGMENT/AGREEMENT SIGNED (Petitioner or Support Enforcement Officer) AMOUNT OF ORDER $ TOTAL BALANCE OWED $ DELINQUENCY $ AS OF (Date) HEALTH INSURANCE ORDERED "X" ALL THAT APPLY CONTEMPT ORDER INCOME WITHHOLDINGPLAN TO PAY PAST- DUE SUPPORT ORDER TO PARTICIPATE IN WORK ACTIVITIES ADDRESS OF COURT (Number, street, and town) ADDRESS OF RESPONDENT (Number, street, and town) It is hereby ordered that the above-named respondent appear before the Superior Court/Family Support Magistrate Division at: ADDRESS OF SUPERIOR COURT/FAMILY SUPPORT MAGISTRATE DIVISION ON (Day of week) DATE (Mo., day, yr.) TIME (A.M./P.M.) ORDER AND SUMMONS to show cause why said respondent should not be held in contempt of court for failure to pay support and/or the child care or unreimbursed medical expense contributions and/or provide/maintain health insurance as ordered by the court or Family Support Magistrate, and/or to show cause why an income withholding, license suspension, and/or an order for a plan to pay any past-due support or an order to participate in work activities should not issue against said respondent. BY THE COURT/FAMILY SUPPORT MAGISTRATE DIVISION SIGNED (Assistant Clerk, Support Enforcement Officer) J. F.S.M 1. You have been summoned to appear in court at: ADDRESS OF SUPERIOR COURT/FAMILY SUPPORT MAGISTRATE DIVISION ON (Day of week) DATE (Mo., day, yr.) TIME (A.M./P.M.) ORDER (For use by Court/Family Support Magistrate Division only) BY THE COURT/FAMILY SUPPORT MAGISTRATE DIVISION J. F.S.M. DATE OF ORDER SIGNED (Assistant Clerk) (order continues on reverse/page 2) CONTEMPT ORDER/INCOME WITHHOLDING The foregoing motion having been heard and it being found that the Respondent is in arrears as of (date) amount of $ INSTRUCTIONS NOT MAINTAINED ADDRESS OF PETITIONER (Number, street, and town) 3. The Superior Court and any Family Support Magistrate may issue an order to suspend the professional, occupational, recreation al, commercial driver's and/or motor vehicle operator's license of a delinquent child support obligor and may order a plan for payment of any past-due support and/or participation in work activities. A "delinquent child support obligor" is (A) an obligor wh o owes overdue support, accruing after the entry of a court order, in an amount which exceeds ninety (90) days of periodic paymen ts on a current support or arrearage payment order; (B) an obligor who has failed to make court ordered medical or dental insura nce coverage available within ninety (90) days of the issuance of a court order or who fails to maintain such coverage pursuan t to court order for a period of ninety (90) days; or (C) an obligor who has failed, after receiving appropriate notice, to com ply with subpoenas or warrants relating to paternity or child support proceedings. 2. If you fail to appear in court on the court appearance date and time shown above, a capias may be issued for your arrest and/or an income withholding may issue against your income. (continued...) I certify that the above information is true to the best of my knowledge and belief: NOT MADE AVAILABLE CONTRIBUTIONS NOT MADE CHILD CARE UNREIMBURSED MEDICAL EXPENSES DATE SIGNED BY AUTHORITY OF THE STATE OF CONNECTICUT, you are hereby commanded to make service of this application and order on the above-named respondent according to law at least twelve (12) days, inclusive, before the court appearance "Date" indicated below. Hereof fail not but due service and return make. To: Any Proper Officer in the it is hereby ORDERED: CITWFRD COURT USE ONLY Then and there by virtue of the original application, and by order of th\ e Court/Family Support Magistrate Division, I served the Respondent with a true and attested copy of the original application, order and summons by (specify method of service) RETURN OF SERVICE 1. If applicable, fill in information required in the "Order and Summons" section and the "Notice to Respondent" section on fro nt before making service. 2. Serve the copy on the respondent. 3. Complete the "Return of Service" section below and return. (Continuation of Order) (State Marshal or proper officer) SIGNED (State Marshal, Support Enforcement Off., Proper Officer) PRINT NAME AND TITLE OF SIGNER DATE SERVED COPY ENDORSEMENT SERVICETRAVEL TOTAL A TRUE AND ATTESTED COPY, ATTEST: JD-FM-15 (Back) Rev. 4-05 INSTRUCTIONS TO PROPER OFFICER The within and foregoing is the original application, order and summons \ with my doings thereon endorsed.