Fill and Sign the Income Assignment Statement Form

 District Court  County Court  Denver Juvenile Court __________________________________ County, Colorado Court Address: In re: Petitioner: v. Respondent/Co-Petitioner: COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom NOTICE TO TERMINATE INCOME ASSIGNMENT To _______________________________________________________ (Employer/Trustee/Other Payor of Funds at _________________________________________________________________________________(address) You are notified that the Income Assignment on _____________________________________(name of Obligee) activated on ______________________ (date) will terminate effective _______________________(date). This notice is issued by: (check one)  Obligee  Obligee’s attorney/representative  Child Support Enforcement Unit  Court   By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country ___________________________________ ______________________________________ (Printed name of Person filing) Signature of Person filing CERTIFICATE OF MAILING I certify that on _____________________________ (date) the original and one copy of this document were filed with the Court; and, a true and accurate copy of the NOTICE TO TERMINATE INCOME ASSIGNMENT was served on the other parties by placing it in the United States mail, postage pre-paid, and addressed to the following: TO: ________________________________________ ________________________________________ ________________________________________ _______________________________________ (Your signature) JDF 84 3/18 NOTICE TO TERMINATE INCOME ASSIGNMENT