q District Court q County Court q Denver Juvenile Court
__________________________________ County, Colorado Court Address:
In re: Petitioner: v. Respondent/Co-Petitioner: Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number:
Phone Number: FAX Number:
E-mail: Atty. Reg. #: Division NOTICE TO TERMINATE INCOME ASSIGNMENT
Courtroom
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) q Obligee q Obligee's attorney/representative q Child Support Enforcement Unit q Court
Dated: ___________________________________
_____________________________________
Signature
Subscribed and affirmed, or sworn to before me in the County of ______________________, State of ________________, this ___________ day of _______________, 20 _____. My commission expires: ____________________ ________________________________
Notary Public/Clerk
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) JDF 84 10/03 NOTICE TO TERMINATE INCOME ASSIGNMENT