Fill and Sign the You Are Hereby Notified Pursuant to Minnesota Law that Fifteen 15 Days from the Date of Form

- 1 - STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, NOTICE OF INCOME WITHHOLDING AND , Respondent, TO : a n d A tto rn ey , Y ou a re h ere b y n otif ie d , p urs u an t to M in neso ta L aw , th at f if te en ( 1 5) d ay s f ro m th e d ate o f th is n otic e y o ur e m plo yer o r p ay or o f fu nds w ill b e in str u cte d to d ed uct y our c o urt- o rd ere d c h ild su pport p ay m en ts a n d p ay m en ts f o r p ast d ue s u pport f ro m y our i n co m e.Y ou c h ild s u pport p ay m en ts a re m ore th an th ir ty ( 3 0) d ay s in a rre ars s in ce th e c o urt is su ed its _ ________ ____ _______ ______ o n _ ___________ _. A cco rd in g to o ur re co rd s, th e to ta l c h ild su pport arre ara g es w hic h date back to th e filin g of th e m otio n on _____________, to ta l $_ _____ _______ . In ad d itio n to w ith hold in g $_ ____________ per m onth fo r ch ild su pport pa y m en ts , 2 0% , o r $ ______ _______ p er m onth w ill b e w ith held b y y our e m plo yer o r p ay or o f fu nds u n til p ast d ue s u pport i s p aid i n f u ll.I f y ou b elie v e y our p ay m en ts a re n ot a t le ast th ir ty ( 3 0) d ay s in a rre ars , o r if o th er m is ta k es of f a ct e x is t, y ou c an d ela y i n co m e w ith hold in g b y r e q uestin g w ith in f if te en ( 1 5) d ay s f ro m t h e d ate of t h is n otic e t h at t h e c o urt:1 . Den y in co m e w ith hold in g o n th e g ro unds th at a n a rre ara g e o f a t le ast th ir ty (3 0) - 2 - day s d id n ot e x is t a s o f t h e d ate o f t h is n otic e, o r o n o th er g ro unds, l im ite d t o m is ta k es o f f a ct, a n d 2. Sta y s e rv ic e o n th e p ay or o f fu nds u nti l th e m otio n to d en y in co m e w ith hold in g is he ard .T he fo rm s in su pp ort o f a m otio n to d en y in co m e w ith hold in g m ay b e o bta in ed fro m _______ ______ County Hum an Serv ic es, Child Support Div is io n, _____________, __ _____ ______ , M in neso ta 5 5____. If y ou re q uest a c o urt h earin g, y ou m ust s e rv e n otic e u pon , a tto rn ey s fo r th e o blig ee. If y ou fa il to s e rv e n otic e, y our e m plo yer o r p ay or o f fu nds w ill b e in str u cte d t o b eg in w ith hold in g c h ild s u pport p ay m en ts f ro m y our i n co m e. D ATED : _ _____________ _ ______________________________ A tto rn ey f o r ( A ddre ss)(A ddre ss)(C ity , S ta te , Z ip )(T ele p hone N um ber)(A tto rn ey R eg . N o.: )