Fill and Sign the Information Statement to the Circuit Court for Missouri Courts

OSCA (10-01) CS80 1of 2 452.350 RSMo IN THE CIRCUIT COURT OF COUNTY, MISSOURI Case Number: Judge or Division: MACSS Case ID: Petitioner: SSN/DOB: vs. Employer/Payor Name: (Date File Stamp) Respondent: SSN/DOB: Employer/Payor Address: Voluntary Income Assignment To: Employer Payor: I, Intervenor Petitioner Respondent, assign, transfer and set over part of my income to Intervenor Petitioner Respondent, in the sum of $ per which includes the sum of $ per to be applied to an arrearage of $ until such arrearage is paid in full at which time the sum assigned shall be reduced to $ per . You, the employer payor are directed to issue checks for the amount to be withheld payable to Family Support Payment Center and mailed to P.O. Box 109001, Jefferson City, MO 65110-9001. This voluntary income assignment shall become effective once it is served on the employer or payor. I understand that my employer or other payor may withhold an additional $6.00 per month for costs incurred. Date Signature of Employee or Payee Address OSCA (10-01) CS80 2of 2 452.350 RSMo Voluntary Income Assignme nt Certificate of Service I certify swear or affirm that a copy of this document was mailed personally served on (date) by registered mail postage prepaid certified mail postage prepaid certified mail return receipt required to (Person/Address) Date Signature Petitioner Respondent Attorney Note: The petitioner, respondent or attorney should cause this voluntary income assignment to be served on the employer. The circuit clerk does not mail or serv e a voluntary income assignment. Service may be shown by acknowledgemen t of receipt, affidavit or by written cer tificate of counsel making such service.