Fill and Sign the Name of Obligee Person Owed Child Support Commencing on Form

Order for Income Withholding July 2014 Page 1 of 3 STATE OF WYOMING ) IN THE DISTRICT COURT ) ss COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT Plaintiff: ____________________________, ) Civil Action Case No. __________ (Print name of person filing) ) ) vs. ) ) Defendant: __________________________ . ) (Spouse) (Print name) ORDER FOR INCOME WITHHOLDING THE COURT ORDERS any payor of (name of Obligor, person owing child support), to pay child support to _____ __________________ ( name of Obligee, person owed child support) commencing on __________________(date). Paymen ts are due on the __________ day of every _________________ (specify time period, i.e. monthly). Total arrears (past due support) owed as of ________________(date) fo r child support is $_____________ . The Court orders the immediate activation of an order for income withholding against the Obligor, pursuant to Wyo. Stat. § 20 -6-204. Income withheld must be paid to one of the two following addresses: Clerk of the District Court, whose address is (see District Court Clerks ’ Addresses in this packet): _______________________________ _______________________________ _______________________________ OR State Disbursement Unit 2300 Capitol Ave. Hathaway Bldg ., 5th Floor, Suite A Cheyenne, WY 8200 2 DO NOT PAY BY PERSONAL CHECK. CASH ACCEPTED IN PERSON ONLY. CASHIER’S CHECKS AND MONEY ORDERS ACCEPTED. The Clerk or SDU shall promptly forward the support payments to the receiving parent at the address pro vided by that parent. Each party shall pay, when due, all fees charged to that party by the Clerk of District Court, State Disbursement Unit, and any other agency statutorily authorized to charge a fee. Order for Income Withholding July 2014 Page 2 of 3 OR Pursuant to Wyo. Stat. § 20 -6-204, t his order for inco me withholding is not subject to immediate activation because either: Both parties have agreed in writing to an alternative arrangement. (When the parties agree to an alternative arrangement, the arrangement shall be in writing, signed by the parties and reviewed and entered in the record by the court. ) OR The Court finds there is good cause not to require the immediate ac tivation of an order for income withholding because: ( The court shall incl ude in the record its findings of good cause, including a statement explaining why implementation of immediate income withholding would not be in the best interests of the child and, in cases involving modification of child support, proof of timely payment s.) Any order for income withholding not subject to immediate activation shall become effective upon the date the O bligor requests withholding commence; or the date the O bligor becomes delinquent in payment of an amount equal to one (1) month's support obligation under the support order as set forth in Wyo. Stat. § 20 -6-205. IT IS FURTHER ORDERED that upon receipt of a notice of Income Withholding for Support , every employer or other person now or in the future owing income to the Obligor shall comply with all terms of the notice and shall withhold a portion of the Obligor’s income and remit it to the Clerk at the address in the Income Withholding for Support form. For purposes of this order: “INCOME ” means any form of period ic payment or return in money to an individual, regardless of source. Income includes, but is not limited to wages, earnings, salary, commission, compensation as an independent contractor, temporary total disability and permanent partial disability , worker ’s compensation payments, unemployment compensation, disability, annuity and retirement benefits, and any other payment made by any payor. Furthermore, n o employer may discharge, discipline, refuse employmen t to, or otherwise penalize an O bligor because o f this Order for Income W ithholding or a subsequently issued Income Withholding for Support form. Order for Income Withholding July 2014 Page 3 of 3 IT IS FURTHER ORDERED that the payor comply with all the terms of an issued Income Withholding for Support form and a ll subsequent notices served upon the pay or; The last known addresses of the Obligor and O bligee are as follows: Obligor (person owing child support) : __________________________ Address: __________________________ __________________________ Obligee (person to receive child support) : __________________________ Address: __________________________ __________________________ IT IS, FURTHER, ORDERED that each party shall notify the Clerk of District C ourt, in writin g, on forms available from the C lerk, within fifteen (15) day s of any changes in address or employment status. At the time this Order for Income Withholding is entered, the C lerk shall mail a copy of the order and the support order to the last known address of the O bligor and the Obligee as listed below .* DATED this ______ day of _ _______ _______________, 20_ ____ _. BY THE COURT: ______ _____________________________ District Court Judge Copies sent to: Plaintiff/Plaintiff’s Attorney’s Name and Address Defendant/Defend ant’s Attorney’s Name and Address * Be sure to include addressed/stamped envelopes for you and the defendant when filing this Order for Income Withholding so that copies of this Order can be mailed by the Clerk as required by law.