Fill and Sign the Respondents Request for Income Deduction Order Case No Form

RESPONDENT'S REQUEST FOR INCOME DEDUCTION ORDER Case No.: Commonwealth of Virginia VA. CODE § 20-79.1 DCSE No. : Juvenile and Domestic Relations District Court V. RESPONDENT PETITIONER ADDRESS ADDRESS SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER I, the undersigned Respondent, state that the following is my court-ordered periodic support payment in this case: } current support $ payable: applied to arrearages $ weekly bi-weekly regular pay dates semi-monthly monthly OTHER PAY INTERVAL AND REGULAR PAY DATES I am also ordered to provide health care coverage for the following persons: STATUS (check applicable box) Former Current Dependent NAME Payment Priority Support 1 . Health care 2. coverage 3. 4. 5. 6. Support of other dependents: I am not providing support to another spouse or another dependent child other than such spouse and/or dependent child(ren) for whom support is to be provided through this case. I am providing support to these other spouse(s) and/or child(ren) for whom no support is provided through this case: I hereby request this court to enter an Income Deduction Order for the withholding from my income of. to be applied to arrearages current support $ $ My employers are: 1. 2. NAME NAME ADDRESS ADDRESS whose normal pay dates are whose normal pay dates are same as above different from above in that I am paid same as above different from above in that I am paid semi-monthly semi-monthly weekly weekly bi-weekly bi-weekly monthly monthly with paydays being with paydays being NORMAL PAYDAY NORMAL PAYDAY I also waive notice of a hearing on the matter. DATE RESPONDENT FORM DC-615 PDF 7/98 } Spouse Spouse Child