Fill and Sign the To Employertrusteeother Payor of Funds Form

JDF 84 3/18 NOTICE TO TERMINATE INCOME ASSIGNMENT  District Court  County Court  Denver Juvenile Court__________________________________ County, ColoradoCourt 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/representativeChild 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)