COMMONWEALTH OF VIRGINIADEPARTMEm OF SOCIAL SERVIces

DIVISION OF CHILD StiPPOR.T eNFOIlCEdENT

PATEIlNITY ACKNOWLEDOMEN'l" RJOIITS AND JlESPONSIBlLILTIES STATEMENT

RJGIITS AND RESPONSIBLmES OF FAnIER:

Please read and a Division ofChild suppan Enforcement employee will read to you the following statements before you sign theAcknowledament ofPaternity form.

1. I understand that my signature on the Acknowledgment ofPatemity fonn establishei 1IIIti am the bioloaical fAther oftheChild for all legal JlUl1lOOCS.

2. I sign the Acknowledgement of Paternity voluntarily and understand thall am under no obligation to do so. No pressure hasbeen placed upon me to sign. I understand I may take the following actions instead ofsigning this fonn.

a. Seck the advice 0< rqnsentltion of legal counselb. Request that blood tesls be taken.c. Have the matIor ofpcemity determined by the court.

3. 1understand I will have the responsibility to provide support for my child.

4. I understand I will be responsible to pay such support until the child tum3 18 yean ofage or beyond, ifrequirod by law.

5. I understand after paternity is established, I have the right to request visitation with and custody ofthe child. Custody andvisi1lotion are decided in lega1 actions separate from !he issues ofpaternity and child support.

6. I understand the Acknowledgment of Paternity may be used in any legal proceedlng ll'ga!ding my child.

7. I understand I have the right to talk to a staffp<nOllto clarify information on this statement and to as!< any questions I have.

8. [ understand that I have the right to rescind this acknowledgment within sixty days from the date of signing unless anadministrative or judicial proceeding involving this child has takm place earlier.

RIGHTS AND RESPONSIBILITIES OF MOTHER:

Please read and a Division ofChild Support EIlforcement employee win·ll'Rd to you the following statements befo<c you sign theAcknowled&mont of Paternity fonn.

I. I undentand that my signature on the Acknowledgment of Paternity fonn means thsll swear that I am the mother ofthenamed child and that lhe person signing as the father is the biological father of the child.

2 I sign the Acknowledgment ofPllernity voluntarily and understand that I am under DO obligation to do so. No pressure hasbeen placed upon me to sign. I understand I may take the following actions instead ofsigning this form.

a. Seek the advice or represeotation of lepl counsel.b. Request that blood tests be takm.c. Have the master ofpatemity determined by the court.

3. I understand after the paternity is established, the father has the ri&ht to~ visitatlon with and custody of diechild. Custody and visitation all' decided in legal acti_ separlle from the issues of paternity and child support.

4. 1undemand that I have the right to talk to a staff person to clarify infonnation on the _ent and to lISle any questions Ihave.

5. I understand that I have the right to rescind this acknowledgment within sixty days from the date ofsigning unless anadminislTlllive or judicial proceeding involving this child has taken place earlier.

ViJainia Code32.1-261 or32.1-269

DCSECASE#:Page 1of2Rev. 07197

ACKNOWLEDGMElIT OF PATERNrryVirginia Department ofHealth/Di\lision of Vital Records

(32.1-257, 32.1-261 0<32.1-269, Cod< o/Virginia)

This statement is to acknowledge paternity of the child described herein. In order for the ralber's name to appear .on the birth certificate of a cbildbom out of wedlock, both biologioal (nahual) p&m1lS must COOlplet< Illd sign this SUllement bel"" a notJl!y public.

PART I - CHILD

\. Full NIIIl1081 Birth:__--,,,,..----,-__-==,.,- -;;= ~=i>.T------

(First) (Middle) (Las/) (Sufflx)

~. S.x;, _

4. Place uf8irth; _

PART n-BIOLOOICAL MOTHER OF THE CHlLD

3.D81coIBir1h: .

5. Birth Certifieatel\ll/llb,r (ifKnuwnj; _

6. Full Maiden Name:__-o=-...,...- ~=_;;_c---------___:==...-----------(Finl) (Middle) (Maid..)

1. Present Name: '"7-c--,- -,~~,.__-------

(FIrSl) (Mlddie) (LiJsI)8. Date omirth; 9. Place of Birth (Slate or Foroign Cou""y): __. _

10. Social Security Numbet' _ I \. Race orColo" _

PART nr -BIOLOGICAL I'ATllER OF TilE ClllW (N01:t:: lrem: i7. )8 and 19 conc.... IJte/a/Jte'q1 the lime gfthHhjid', birth!

12. Full NllIlc: =-,.-=-==...,- ~_,_,-----=_"""";_------------

(Fir") (MIddle) (lmQ (Sojflx)13. Date ofBirth; l,4. Place of birth (Siall or Foreign Co""ty):. _

IS. Social Security Numbet', 16. Race 0' Color: 11. HigheSl Level of Educalion Completed, _

18. Oceupation" _ 19. Industry.: _

PART IV· BIOLOGICAL PARENTS' MARRIAGE (iF APPLiCABLE, You "nal compl~te this ncrion and enclose a c,r'i,fi,d copy ofYOlir mD"iDgerecQl"d)

20. Place of Marriage', =-:::-_---,=.,-- .--;:-_-, 21. Date ofMarriage,(CitylCounty and SUzIe, or ;:-....Ig. Co",,,,y) ---------

PART V _PARENTS' ACKNOWLEDQMENT (THIS n'EM MUS!' DE COMPLETED)22. We, being duly swom, affum that we are the biotogk:a( parent" of the child named Above, ....-e bave read the rights and respoosibililics statementattached to our (;Opy oftbis docwnent, and we request that the father's information be shown on this ch.ild's hinh certifieatc. and that the child's namebe listed on the birth certificate as shown below.

Child's Name'__n::;::::;- ==...-----------==----------,..(Fir") (Middle) (JArI) rs,;o:,;)--

23. a. Silll'alUre of Fathtr. _

b. Address of Fad1er' _

25. Subscn"bed an sworn before me on: _

21. Notary's ,ignalute, _29. Notary's address; _

31. My COmrDLsslon expira: _

032·II-VS22(II9S)

24. 8. Silll'8lUre of Mother' _

b. Address of Mothcr; _

26. Subscribed and /Wom before me 00' _

28. Notary's ,;8l'alure' _

30. NotJl!y's add....' . _

32. My Commissionexp;res' _

2-- of "LAPECS~OS

ADMINISTRATIVE SUPPORT ORDER OCSE.FIPS#

COMMONWEALTH OF VIRGINIADEPARTMENT OF SOCIAL SERVICESDIVISION OF CHILD SUPPORT ENFORCEMENT (DCSE)801 [AS MAIN STREET, RICHMOND, VIRGINIA 23219

[ JTHIS ADMINISTRATIVE SUPPORT ORDER (ASO) IS BEING REISSUED IN ORDER TO CORRECT A CLERICAL ERROR

IN THE ORIGINAL ASO.

Obligee,Custodial Parent (CP)

v. Obligor::'\ioncustodial Parent (NCP)

{ ) lde-ntil)'ing information not provided pursuantto Va. Code ~ 63.2-1916.

( 1 Identifying informdtion 1I0t provided purSudntto Va. Code ~ 63.2.-1916.

Residential Address: Rpsidential Address:

Telephone ~umber(s): Tc.-lephone :'\uOlher{s):

Mailing Address if Different Mailing Addrpss jf Diffenmt:

Sodal S«urity Numbt'r:Driver's License ~umber & Stdt£'·Date' of BirU,:

Social Security ~umber:

Driver's Liten.st> ~umber & 5t"I(>:Date of Birth:

Employer: Employer:

Addrf'5S' Address:

The [ 1Common ......ealth of Virginia or [ 1the StAte of. .__.. _ _ ._._ is providing child supportt>n(orn~mentSflrvices for th{' persons identified below. LJnd~r Virginid IdW. the following dl'pendent(s):

Name SOC. SEC # SEX lXJK RELATI01\5HIP TO NCr

is (are) ~ntitJl!'d to support from tht> NCr, who has d financial obligation to pay through tht> DCSE according 10 thp statt'menls checkedbelow. ThprE"(ore, thE" Commonwealth of Virginia, Departlllf"nt of Social Services, Division of Child Support Enfon:t>nu-nl. ORDERS theNCr to pa~' as follows:

[I 5___ _ _ per month current child support.The first monthly payment is due on thE> I~ day of the next month following the efle"Ctivl' d.'tlE" of this order. which is the datethis;. order is servt>d on the cr (or the Notice of Proposed Review is served on thl;' nonrequesting p.arty in thE" case oi aReview and Adjusbnent), and on tht' 1'1 day of each month aftt>r that. In addition to the stated monthly amount, thE:' "CPalso shall pay a prorated amount covering thE' period hfoginning on the date the 'CP is served with this ordpr dnd the firstday of the next month, or in the case of do Review and Adjustment, the datt> the nonrt>quE"sting pdrty ' ...as ser\'ro with thE'~oticf' of Proposed RE'viE:'w and thE:' first dar of the nE"'(t month.

I I 5 _ pt"r month toward olrreJrs.

TOTAL S Jl(>r month paYdble ~s set forth aoo\'t>. hereinafter "total support obligdtion."

ArECS 202 Rev. 06-12PAYMENT

ARREARAGESThe NCr's tolal arrE'drage rquals S induding pnncipal, intt'rt"st and fees, for tht· period______ through ~ All or J pNtion of this IIrredrdge may be- OWN ttS a dpbt to the (ommonwe"lth of Virginid

or the Stolte of . Jor reimhursement of TANF paid to your dependent(s), for foster (df\' providr-d to yourdependent(s). or Il\dY be owed to the Commonwealth ot Virginia's Dt"partment of Juvpnilt> Justice ~ginning thft date yourdependent(s) was (werp) received by the Dt>pcHtmenl if rtpplic'lble. If additional arrears haw nnlllP.f>n dsSt'Ss~d. DCSE r~:st>rve5 theright 10 4SseSS surh arrears and demand such paymtc"nt in tht> future as they become due.

Page 1 of r

If an income withholding has not been sent to your employer, you must pay your ...-hild support by using electronic funds transfpr,surh as Virginia $4Kids on the DCSE website (\\-..v\\ ,dss..\irginia.go\"'famih'dcs,e.htmJ) or Western Union; by paying through yourbank's on-linE' bill payment service; or by mailing a personal chefk, cashier's rhf'rk, or money order for the dmount owed each monthmade payable to the Treasurer of Virginia. INCLUDE YOUR CASE NUMBER ON THE PAYMENT. Mail the payment tu;

Division of Child Support EnforcementP.O. Box 570

Richmond, VA 23218-0570

SUPPORT PAYME1'.'T5 ~IA) NOT BE MADE DIRECTLY TO rHE FAMILY. PAYMENTS MUST BE MADE TO DCSE Payment,made directly to tht> custodial parent or children, bills paid for them, or clothing or supplies purchased for the family are consideredgifts and MAY NOT BE APPLIED TO YOUR support dccount.

The parties hereto shall provide to DCSE at least 30 days written notice, in advance, of any proposed changE" of residentidl and, ifdifferent, mailing address and of any change of telephone numllt"r within 30 days of the change. F.ach party hereto is required to keepDCSE informed of the name, address, and telephone number of his or her employer(s).

The support ordered herein shall continue until the next due date after the child's eighteenth birthday, EXCEPT THAT for ed...-h childwho is (i) a full-time high school student (ii) not self~supporting,and (iii) living in tht.~ home of the parent seeking or receiving support,support continues until the next due date after the child's nineteenth btrthday or graduation from high school, whichever comes first.

WARNING: ANY FAILURE TO PAY WILL RESULT IN ENFORCEMENT ACTION TAKEN BY DCSE

Any overdue support will be subject to enfoRemen! dction, including income withholding,. liens, state and tederal tax refundinten.'t:'pt, vendor payments and lottery winnings interc('pts, orders to withhold monies tram bank and other acrounts, passport denial,booling of vehicles, foreclosurf' and seizure dnd sale of property, reporting delinquent dn::ounts to mnsumer reporting agencies,charging interest on arrearage amounts owed, and suspension/ revocation of licenses issued by the Commonwealth-includingprofl"ssionaI, occupational, recreational, driver's and other licenses. In addition, if any overdue support, induding interest or fees,exists at the time the youngest child included in this order emdlKipates. payments will wntinut' in the total amount due (currentsupport plus amount applied toward overdue support) at the time of l"mancipation untH all overdut' support has been paid.

A licl"nse, certificate, registration or other authorization to engage in a protession, bU!~iness, trade. ocrupation, or recreational activityissued by the Commonwealth of Virginia is held as follows:

Respondent Petitioner TYPE OF LICENSE AGENCY GRANTING LICENSE

---_._--- ..

LICENSE NUMBER

HEALTH CARE PROVISIONS

[l The NCP is ordered to provide health insurance for the dependent children who dfC' the subject of this order and isrequired to provide to DCSE with the health insurance policy information and to provide to the CP the dowment ordocuments necessary (or the use of surh l'overage by the dependent children

[1 lbe CP is ordered to provide health insurdlKl' for dependent children and is required to provide DCSE witll the healthinsurance policy information.

[l Health insurance is not availabl{'> at a reasonable cost as defined in Va. Code § 63.2-1900 and therefore neither the CP nortile NCP is ordered to proVide health insurance. At such time as health insurance Monws available at a reasonable costas defined in Va. Code § 63.2-1900, the party to whom such hE'alth care coverage be<omes available (either the CP or thE'NCP) is required to inform DCSE at thf' address shown at the end of this order of that availability.

Page20f tor

APEes 102 Rn. 06-12

CASH MEDICAL SUPPORT

An\' reasonable and ne\.'essarv unreimbursed medical and dE"nlal expenses, in excess of $250 for dny calendar year. foreach child covered by this order shall !:Ie paid in the following Tiltia:

INCOME WITHHOLDING

I 1 lncorne withholding is ordered for the (urren! support obligation. If dfflMrs cUe owed. itO additional amount equal 1025% of the current support obligation or $65 per month, \\"hichever is greater, will be withheld. It may take severalweeks for the child support deductions to begin. Until they begin, you Me responsible to Ill"il in the payment tothE> address in the Payment Instructions section of this order. If DCSE finds good cauS(> or by written agrl'ement of theparties. the income \\:ithholding will not be sent to your employer at this tinll:'. it pdyments are not made as ordered,however, incom~withholding will be implem~nted C1nd notice will be provided to you through your employer.

CALCULATION

The support amount ordered herein:[I resulted from use of the ( J sole [ ] shared l J split custody child support gUidelint' set forth in Va. Code ~ 20~108.2.

constitutes d deviation from th'" child support guidelines because use of the guideline in this case would 1Jt> unjust orinappropriate dft~r considering relevant fador(s) listed in the attached obligation calculation worksheet (which isincorporated herein by reference). Use of the guideline in this case would Il<lve resulted in a child support amount of$_.__.~

APPEAL RIGHTS: IMPORTANT INFORMATIOS - THE FOLLOWING APPI.IES TO ALL ORDERS

The cr or the NCr may appeal this order wilhin 10 calendar days of receipt. If no appeal is made on or before 10 calendar days tramthe receipt of this order. the above child support amount and arrearage are legally f'stablishf'd. TO APPEAL, A WRnTE~ REQUESTMUST BE SENT TO: HEARING OFFICER, 801 E,dst '-'ain Street. Richmond. VA 23219-3301. The ret.{uest must wntain the names ofthe Ncr and cr, DCSE case number and the reason for the appeal. An administrative hearing officer of the Department of SocialServices will hear the appeaL If you disagree with the hearing officer's decision, you Illay appeal within 10 calendar days of the dateyou recltivE' the decision to the appropriate Virginia Juvenile and Domestic Relations District Court. If you Jive in Virginia, the appealshould be filed where you reside. [f you are a nonresident of Virginia, the appeal should be filed wher-e the other party resides. Ifboth parties are nonresidents. the appeal should be where the NCP has property or where the NCP's employer is located. If marcthan onE' court is available, then the party filing the appeal should choose the location.

This order creates a judgment by opt"rahon of law and as such is entitled to full faith and. credit in ,my otheT state or jurisdiction. Thisorder remdins in full for....e dnd "ffQCt until amPlldpd or annulled by this agelKy or the appropriate court.

DCSE DOES NOT DETERMINE LEGAL CUSTODY AND VISITATION.LEGAL CUSTODY AND VISITATION CAN ONLY BE DETERMINED BY THE COURT.

REVIEW OF ORDER

Page 3 of It APEeS 202 Roy. 06-12

The cr or th~ NCr mlllY request a review of thi.!o ordt>r every thrl?(' YPtlfs. A rpvi(' ..... may N' re-quesh'd earlier if there is a change in thenumber of children of U1P parties to this OrliN. it chdnge in the availability of health insurance. or a documented change of at least 25%(nigher or lowf'r) of any of the following: income. cost of health insuretnCf" or dpppndent (drE> exJ.>t?nse. To begin the revie\\' p r(1({"Ss,provide a written request to the- district office shown below. OCSE will rf'quin~ both potrties to pro.... ide information about income and(t'"rbtin expenses. nh~' revit>\\.· may result in an increaSE". d da:rease. or no change in the amount of your support order.

Virginia law requires the CP and the NCP to provide written notincation of it change in his or her home and work addresses itS well ashome and work telt>phont> numbt>rs wiUlin 30 days of d change. Report changes to DCSE. IN ANY FL'TLRE ACTION, DCSE MAYSERVE DOCUMENTS BY fIRST CLASS MAIL TO THE MOST RECENT RESIDENTIAL OR EMPLOYER ADDRESS FILED BY EITHERTHE CPOR THE NCP WITH DCSE OR A VIRGINIA COURT HAVING JURISDICTlOl\: IN THE MATTER.

Distrkt Offirp

Dale

/s/Nathaniel L. YoungNdUldniel L. Young, jr.. DirC'CtorDi.... ision of Child Support Enforn>ment

Tplephonp NumbE'r

Virginia Codt' 5e<"hons: b.J-3305416.1-29046.2-32<.163.2-190363.2-1904

b3.2-I90S63.2-191063.2-191663.2-191763.2-192~

63.2-193763.2-194263.2-194.163.2-1952

I.__~__ . ..__~. . d duly auUlorized employee of the Di.... ision ot' Child Support Eniorct~ment,hereb\" (""ctif"that I mailed a true copy of this administrative support ordpT to the NCr at the address SE"t forth on this document. in compUan~p with-V•. Code § 63.2-1916 and/or Va. Code § 8.01-296(2)(b), on __/ __/ .

Signature

APECS 202 Rev. 06-12

COMMONWEALTH OF VIRGINIADEPARTMENT OF SOCIAL SERVICES

Adm~nistrat1ve Hear1ng Decision

Distr1ct Office:DCSE M;Oate of Mear1ng:Support Special 1St:

DECISION

In cons1dering the objection, tho Hearing Officer must determine what~e~ ~heSupport Specialist properly complied with the Program Manual o~ the D1V1S10nof Child Support Enforcement and as prescr1bed in Chapter 19, Title 63.2 ofthe Code of Virginia.

After cons1dering the evidence and testimony offered at the hearing, andreviewing the case, it is the ruling of the H••ring Officer that the actionindicated below is: AMENDED

X Administr~tive Suoport Order, pursuant to 63.2-1916 of the Code ofVirginia dated .Order/Notice to W~thnO!a Income for Ch11d Support. pursuant to 63.2-1924of the Code of Virginia datedOrder to Withhold and Deliver, pursuant to 63.2-1929 of the Code ofVirginia datedState Tax Set-off, pursuant to (58.1-520 at seq.) of the Code of VirginiadatedFederal Tax Set-off, pursuant to the Code of Federal Regulations, Section303.72 datedAdvance Notice of L~en datedCredit Bureau Notification Letter datedOther

Comments:

Right to Appeal

X From the decision of the Hearinq off~c.r there shall be a right to anapp.al de nova to the Juv.n~le and Dome.tic Relations District Court.The appeal may be taken by filing a written petition with the Clerk ofthe appropriate court.

An appeal shall lie to the circuit court with respect to determinationsunder the Set-off Debt Collection Act pursuant to Article 21(58.1-520 atseq.) of Chapter 3 of Title 58.1 concerning state income tax overpaymentsand with respect to federal income t •• debt set-off aetions. The appealmust be taken by tiling a written petition with the clerk oL theappropriate court citing this section as authority to review the decisiono~ the Hearing and Legal Services Officer.

The authority toCode of VirginiaTAKEN WITHIN TEN

appeal the Hearing ~ticer,s decision is provided for ~n thesections 63.2-1942 ,,63.2-1943. SUCH APPEAL SHALL BEDAYS OF RECEIPT OF HEARING OFfiR';;j,DCISION.

/11111)1)111' C LW--... -,ltn:-'J, ,r.//;;.t,,;:;....,;.,C.---.::.::~ --=-'LL~"l~..':--_

Hear~ng Officer: EMMA K. NESBITT

Date of Decision:

cc: District Off~ce

Custodial Parent

Division :)f Ch'!d :;ll~P{)rt ,V'/inchcsl')r Ol1k.e ,._----_.__... --

COMMONWEALTIi OF VIRGlI\lADEPARTMENT OF SOCIAL SERVICES

DIVISION OF CHILD SUPPORT ENFORCEMENT

REVIEW AND ADJUSTMENT TERMINATION NOTICE(I)

DATE: (2)DCSE#: (l)

Dear (3)

The review for possible adjustment of your child support order by the Division of Child SupportEnforcement (DCSE) is being terminated for the reason indicated below.

(4) The party who asked for tbe review bas failed to provide requested information.

(5) Thc requesting party has withdrawn the request.

If the review is being terminated because the requesting party has withdrawn the review, theother party may ask DCSE to continue the review action. 'Ihe other party must send a writtenrequest to the office listed below within 10 days from the date of this letter. If the other partydoes not send a written request, DCSE will end efforts to review the child support order.

Terminating a review does not mean that either party cannot request a review at a later time.Either party may request a review anytime after 36 months from the time an order was entered orreviewed for possible modification, or earlier if there is a significant change in circwnstances.Either party may also try to have the order adjusted at any time through the courts.

Ifyou have questions, please contact the child support enforcement office listed below:

Sincerely,

-(6).-,--:-=----c--­Authorized Representative

__(6).~ _Telephone

_(6). _

APECS 20G-Rev. 07/06

INCOME WITHHOLDING FOR SUPPORT

( ) ORIGINAL INCOME WITHHOLDING ORDERlNOTICE FOR SUPPORT (IWO)( ) AMENDED IWO( ) ONE-TIME ORDERlNOTlCE - LlJMP SUM PAYMENT( ) TERMINAnON OF IWO Date:: _

( ) Child Support Enforcement (CSE) Agency( ) Private IndividuaVEntity (Chock one)

( ) Court ( ) Attorney

NOTE: If you receive this document from someone othet than a State or Tribal Child Support Enfa«:ement agoney or a coun,a copy of the underlying order that contains a provision authorizing income withholding must be auaehed. Or ifundet Statelaw an anomey in that State, or if under Tribal legal representative, may issue an income withholding order; the anomey ortribal legal repIUClltative must include a copy of the State or Tribal law authorizing the attorney or Tribal legal representativeto issue an income withholding order.

StateffnllefferritoryCity/Co./Di.!lJfribePrivatellndividuaJlEntity

Commonwealth of VirginiaVIRGINIA DlV OF CHILD SUP ENF

Case IDOrder 10, _

RE:(Employer's/Withholder's Name)

(Employer'slWithholder's Address)(Emp!oyer'slWithholder', Federal EIN H)Cbild's Name Birth Date

(Employee's/Obligor', Name)

(Employee'siObligor's SSN If)(Employee's/Obligor's Case 10)(Obligee's Name)

Arrears greater than]2 weeks?

( lye, ( )no

ORDER lNFORMATION: This document is bued on the ,upport or withholding order from _ .. ~. You arerequired by law to deduct these amounts from the employee's/obligor's income until further notice.S current child ,upportS past·due child supportS current cash medical supportS past·due cash medical ,upportS ,pousal ,upport$__ past~due spousal supportS other (specify)for a total ofS per MONTH to be forwarded to the payee below.

...m~~WTIlIH;:r,- ~:~';;'no;ha~e;o ~~;o~~~;:cycle l~~in compliance with~your pay cycle doe, not match the ordered payment cycle, withhold one of the following amounts:S per weekly pay period. S per semimonthly pay period.S per biweekly pay period S per monthly pay period.

REMITIANCE INFORMATION: If the employee's/obligor's principal place of employment is Virginia, begin withholdingno later than the first pay period occurring one day after the date ofthl, notice. Send payment within the same working day ofthe pay date/date of withholding. The total withheld amount, including your fee, may not exceed % oftheemplcyee's/obligor's aggregate disposable weekly earnings.

If the employ",,'s!obligor's principal place of employment is not Virginia, for limitations on withholding, applicable timerequirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor" principal place ofemployment (see ADDITIONAL lNFORMAnON TO EMPLOYERS AND OTHER WITHHOLDERS).

Document Tracking Jdenti6er. _ o:vm: 0970-0154 p. I cf- J

Employers with mort than 100 employees and payroll proc<"in~ fums with more lOan 50 clients m\l3t submit childsupport .payments via electronic funds transfer. If remitting payment by EHIEDI, call 1·800·257.9986 before first subm,U1Oll. Remllwi1hin four worl<in& days of the pay date/dele of withholding ,I' submitting by electron,c fund, tnmsfer (EFT).

For EJ'l1ED1 illsttuctions, contact the EJ'lIED! office at 'he web,ite listed below. If paying by cheek, make check payable to:TreasurerofVlrginia. Include this Retntttance Idenllf,Cf with payment:Send check to:

Division of Child Suppon EnforcementP.O. Box ~70

Richmond, VA 23218-0570

FIPS Code (ifnecessary):: _Sill/lature (if mjuired by Slate or Tribal I.")._Print Name:Title oflssuing Official:

( ) Ifcheclu:d, you an mjuired 10 provide a copy of this fonn to your employee/obligor. If the employee works in a State orfor a Tnbe that is different from the State or T:ibe tbat iS$ued thi-fi order, a copy must be provided to your employee/obligor

even if the box is n01 checked

ADDITIONAL tNFORMA TION TO E:'vIPI.OYERS AND OTHER WITHHOLDERS

State-specific information may be viewed on the OCSE Employer Services website located at:bUP;jIwww.•d.hh••gov!programsls5e!nCl\·hirclcmployerlsontlst:llsont.clS.htm

Priority: Withholding for suppon has priority over any other legal process under StI10 low (or tribal law, if applicable) agwtthe wnc income. If there are federal tax levy is in effect, please notifY the conllltt person lisled below.

Combining Payrnenli: You may combine wilhheld amount!. from more than one employet:'s/obligor's income in a.ill8le paymenlto each agency/party requO:Slin~ Withholding. You must, however, separately identify the ponionof the single payment that ,s attributable lo each employee/obligor f.mployer.i with mo~ than 100 employees andpayroU processing films with more than SO clien!,:; musl submit child .sUppOC1 payments via electronic fundstrIlI.sfer.

Reporting dle PaydatelDate: You must repun the paydatc/dalc of withholding when sending the pa)'ment. Thepay date ~ the date on which the amoun: was wiLhhdd from the c=mployee's wages. You must comply wi.th the law of the State(orTribellaw if applicable) of cmplnycc's/t'bllgor's principal place of employment with respect to the time periods withinwhich you must implement the withholding Me! fnrw""tf, th~ ....N'....., ("",..nc:nt ...

EmployeoiOblillOT with Multiple Support Withholdings: If there is more than one OrderlNo!i.. against this employee/obligorand you are _blelO bonor all suppon OrdersINolice, due (0 federal, State, or TriboJ withholding limilS. you must follow theStile or l'ribotllaw/pro<:e<l= of the employee';!obligor's principal place of employment. You must honor all OrdessINoticesto the greatest extent possible, giving priority to current suppon before payment of any past-due support.

If you have questions regarding thi, order for incom. deduction> for support, you may call the Employer Inquiry helpline 1Il 1_SQO..257·9986 or you mel' COnlllCt your district office listed below.

Lump Sum Payments: You may be requited to repurt and withhold from lump sum payments such as bonuses,commission~ or severance pay. Contact the agency or pcrsO:'L listed below to determine if you are required towithhold or if you have any questions about IU,:lp s.um payme:H$

LiabIlity: Ifyou have any doublS about the validi" of 'he Order"-:-;nticc, contact thc agency or person IiSled below. If you failto withhold income as the OrderlNotice directs, you are liable tor both the ateumuialcd amount ynu should have withheld fromthe employee'.s/obligor's income and any other penalties set b)' ,\ta1(: or tribal law/procedure.

OMR Expintion nate -10Dlt20l0. The OM;) r.;o.piration Out~ has no~g On the termination date or v&.Iidity of theincoml witbbolding ordu; it identifies the version or the for rn (IJ[Tt:ntly in use.

Page 2 .f .3

Employee'S/Obligor's Name;Employer's Name:

Case ID:Order ID:, _

Anti-discrimination: You are subject to a flOe delennined under State or Tribal law for discharging an employee/obligor fromemployment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child supportwithholding.

The employee's!obligor's rights are protected pursuant to the Virginia Code §63.2-1944. IF YOU FIRE, REFUSE TO HIRE ORTAKE DISCIPLINARY ACTION AGAINST AN EMPLOYEF.JOBI.lGOR BECAUSE OF THlS ORDER, YOU ARE LrABLE FOR ACIVIL FINE OF UP TO $1,000.00.

Withholding Limits: For state orders, you may not withhold more than the lesser of: I) rhe amounts allowed by the FederalConsumer Credit Protection Act (15 U.S.C. § 1673(b); or 2) the amounts allowed by the State or Tribe oftheemployee's1obligor's principal place of employment. Disposable income is the net income left after making mandatmydeductions such as: State, Federal, local taxes, Social Security Iaxes, StalUtory pension contributions and Medicare taxes. TheFederal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income ifthe obligor is nol supporting another family. However, that 50010 limit is inereased to 550/. and that 60010 limit is increased to65% if the arrears .... greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. Thesupport amount and tbe fee may Dot exceed the limit indicated in this section.

Virginia employers may (but not required to) deduct a 55.00 fee to cover extra administrative costs for each deduction forsupport or for each reply tbat DO funds are available. This amount is in addition 10 the amount of the income deduction.

By law, the employee/obligor can contest this OrderlNotice to Withhold Income for Child Support only if theemployee/obligor

is DOt the person cited or there is a mistake in the amount of support owed. If the employee/obligor contests this order, theemployee/obligor must tile a written request for an appeal hearing within 10 days from the dare ofreceipt ofthis notice. Sendthe request for an appeal hearing to the Hearing Officer, 80lEast Main Slreet, Richmond, VA 23219-2901. Theemployee/obligor will be notified of the tiroe and place of the hearing. The employee/obligor will be given the opportunity topresent hislher objection ro this OrderlNotice to Withhold Income for Child Support pu...uant to Virginia Code sections63.2-1924 and 632-1942.

Arrears greater than 12 weeks? If the Order Information docs Dot indicate whether tho arrean are greater than 12 weeks, thenthe ctIlployer should calculate the CCPA limit using the lower percentage.

For Tribal orders, you may Dot withhold more than the amounts allowed under the law of the issuing Tribe. For Tn'balemployers who receive a State order, you may not withhold more than the lesser of the lim~ set by the law oflbe jurisdictionin which the employer is located or the maxirown amount permitted under section 303(d) of the CCPA (15 U.S.C, 1673(b»).

Depending upon applic&ble State law, you may need to take into consideration the amounts paid for health care premiums indetetmining disposable income and applying appropriate withholding limits.

Additional Information: The total you can deduct for either the insurance premium. the support payment. or a total of the two cannot exceedthe peroenmge shown on the order.

Ifyou cannOI withhold enough 10 cover both lbe support payment and the insurance premium because their total exceedsthe maximwn percenlage allowed under the Consumer Credit Protection Act, your priority is tho item ehcd<ed below:( ) iQSUronce premium ( ) support payment

Virginia Code Sections:21).79.1 21).88.64; I20-79.2 21).88.64:220·79,3 21).81.6>\:3

20.81.64:420.88.64:~

34-29

63.2-190063.2-192363.2-1924

63.2-192563.2-194263.2-1944

63.2.194~

lMPOilTANT: The person completing this fonn Ls advised that me infonnation on this fonn lIlly be shared with the obligor.

Page 3 cf >

COMMONWEALTIl OF VIRGINIADEPARTMENT OF SOCiAL SERVICES

DIVISION OF CHILD SUPPORT ENFORCEMENT

Advance Notice of Lien(Virginia Court~)

RE:

DCSE#:

Dear:

According to our records, you OR delinquent in your child suppo" payments.The information we bave is as follows:

Time period in which arrears accrued: From to

Total support llue for this time period:

Total payments made for this time period:

Remaining arr.... llue for this time period:

Dependents:

The amO\lllt due is not neceosarily the entire amount of your debt but may represent a partial figure. Based'on thisinfonnation, a lien will be filed and the lien information may be provided to the credit bureau. rr additional debtaccumulates .fter receipt QUllis notice, addltion.IUens may be filed without furtber notice.

If you believe our information is incorrect, you may file a written request for an appeal within 10 days from the date ofservice ofthis notice to the Hearing Officer, 801 East Main Street. Richmond, Virginia 23219-1849. You will be notifiedof the time and place of the hearing and, pursuant to the Section of the Code of Virginia referenced below, You will begiven the opportunity 10 present your objection.

Ifyou disogree with lbe hewg officer's decision, you can appeal to the courts of the Conttllonwealth within 10 day> ofreceipt ofthe decision in accordance with the section of the Code of Virginia referenced below.

Sincerely,District Office:

Authorized RepresentativeTelephone

Virginia Code Section63.2-1916

APECS 406 - Rev. -3108

Date

DISTRICT OFFICE ADDRESS

COMMONWEALTH OF VIRGINIADEPARTMENT OF SOCIAL SERVICESDIVISION OF CHILD SUPPORT ENFORCEMENT

TELEPHONE NUMBERCONSUMER AGENCY REPORTING NOTICE

FAX NUMBERDO ~ CUSTODIAL PARENT'S NAME

NCP'SNAME

NCP'S ADDRESS

Dear

Credit reporting agencies maintain records. which tell creditors what debts you have andwhether you pay those debts on time. This may affect your ability to obtain fUlUre credit.

Federal and Virginia laws require the Division of Child Support Enforcement (DCSE) toreport support arrearage information to credit reporting agencies. According to DCSE's records. as of theabove date. your support payment arrearage total (including interest) is _

This is a NOTICE to you of our intent to report your support arrearage information tocredit reporting agencies. DCSE will report to credit reporting agencies. each month. whetheror not you are making your support payments as ordered. In addition. DCSE will reportthe current balance of your support arrearage. TO A VOID having your past due support informationreported to the credit reporting agencies. you must. within 10 days of receiving this notice. pay your pastdue support in full.

Paying your past due support in full or making your payments according to the terms of your orderwill nOI only reduce your arrearage. it may also reflect favorably on your credit report.

Mail your personal ch~k. \:ashier's check. or money order. mad~ payable- 10 the T.-eas:urer (\f Virginia.Include your social security number on the payment. Mail the payment immediately to lhe DivisiOD orCbild Support EDroreemoDI, PO Bos 570, RiebmoDd, VA 23218-0570.

DO NOT INCLUDE ANY CORRESPONDENCE WITH YOUR PAYMENT. Mail correspondenceseparately to the district office listed at the top of this notice.

If you have information that the past due support shown on this notice is not correct or if you do notowe support. you may contest this action. To contest this action. contact the district office listed on thisnotice WITHIN 10 days orthe date of this notice and request an administrative review.

Credit reporting agencies may obtain past due support information from public court recordsand enter the information into their files without DCSE involvement. This notice relates only to

our direct reporting to the credit reporting agencies.

l\'OTICE: ~tion 7 ortbe Prine)" Acl (~ l;S(' 5~2.) lad Smion -'66(1)(13, oftht: Soc:ial MfUrll)' :\(11·12 t:SC 666(I)(I3Urequirt.1I individuals lubjecllo c.i1d suppor1 order":' 10 pro\>'ide .lIIeir sMi.1 Heurit)' n.mben. Tbne numbtn will H k.ePli. tbe ease fttonh. aDd will only M .se-d to locale iBdi\'iduals for ptlrposn of ntablislling patentity BAd ellablishing.MOdifying. aDd enforcing support obUgatioali.

42 USC §666Code of Virginia §63.2-1940 APE('S-40408/07

District Office NameDistrict Office AddressDistrict Office Address

District Office Tele No.

Dale of Document

COMMONWEALTH OF VIRGI:-.iIADEPARTMENT OF SOCIAL SERVICESDIVISIO:-.i OF CHILD SUPPORT ENFORCEMENT

NOTICE OF INTENT TO SUSPEND DRIVER'S LICENSE

Custodial Parent (S) Names

Noncustodial Parent's NameNoncustodial Parent's Delivery AddressNoncustodial Parent's Post Office, State, Zip Code

DearTAKE NOTICE that the Division of Child Suppon Enforcement (DCSE) demandsimmediate payment of your past due suppon.

According to the DCSE's records, as of the above date, your child suppon is past due in the amount of$ and a payment has not been received from you in 90 days or more. Virginia law allows theDCSE to request suspension ofa noncustodial parent's driver's license ifpast due suppon is at least $5,000 ormore or is past due by 90 days or more. This is an advance notice of our intent to request the Depanment ofMotor Vehicles (DMV) to suspend or refuse to renew your Virginia driver's license for nonpayment of childsupport. The DMV will notify you when your license is suspended.

The DMV will not return your driver's license until the DCSE tells the DMV that you have I) paid your pastdue suppon in full or 2) reported to DCSE and signed a negotiated payment agreement.

TO AVOID SUSPENSION OF YOUR DRIVER'S LICENSE OR FURTHER COLLECTION ACTION, youmust. within 33 days of the date of this notice. I) pay your past due suppon in full or 2) report toDCSE and negotiate a payment agreement. Current suppon must be si:ltbl1c:u bdun: paymcm:s arc applied to

arrears balance. If you make a payment on your arrears, but fail to report to DCSE and negotiate a paymentagreement the DCSE will proceed with the suspension OfyOUf driver's license.

Interest will be charged on the arrears until it is paid. The current interest rate is Six percent annually.The interest rate is subject to change.

PA YMENT INSTRUCTIONS

Mail a personal check. cashiers check. or money order for the amount you O\VC. Make the paymentpayable to the Treasurer of Virginia. Include your social security number on the payment. Mail thepayment immediately to:

DIVISIO,," OF CHILD SI.lPPORT ENFORCEMENTPO BOX 570

RICHMOND, VA 23218·0570

Page I of 2APECS -WO-Kc\. {" 10

(Date of Document)

DO NOT INCLUDE CORRESPONDENCE WITH YOUR PA YMENT. Mail correspondence to thedistrict otlice listed on this notice.

You have the right to request a court hearing if you believe that your failure to pay the past duesuppon was not willful. To request a hearing. mail or deliver a \\rinen request to the DCSEDistrict Otlice listed on this notice WITHIN 10 days of receiving this notice. The Division willfile a petition with the appropriate circuit or Juvenile and Domestic Relations District Court.You will be notified of the date. time. and location ofthc hearing. If a court hearing isrequested. the DCSE will postpone action to suspend your driver's license until after thehearing.

You also have the right to request the Juvenile and Domestic Relations District Court in the cityor county where you live to issue a restricted license.

If you have information that the past due suppon shown on this notice is not correct or you donot owe support, you may contest this action. To contest the action. contact the district officelisted on this notice WITHIN 10 days of receiving this notice and request a case review.

Code of Virginia 46.2-320

NOTICE: Section 7 of the Privlcy Act (5 liSe 5521) ..d Section 466(1)( 13) of the Social Security Act 142USC 666(1)(13)1 require- all individuals subject to child support orders to provide thtir social securit),numbers. These numbers will be kept in the use re<'ords. Ind will onl)' be used 10 locate individuals forpurposes 01 f"Stablishing paternity and esbblishing, modifying, and enforcing support obliptions.

Page::! of2 A PEeS 400 . Rev. 6/1 0

PETITION FOR RESTRICTED DRIVER'S LlCENSE­FAILURE TO PAY CHILD SUPPORT

VA CODE*~462-3201.181-~711

I'f.TITIO~FR.

nTY'STATt

Case !'rio.

IlrARING D/\TI-::

Juvenile and Dom~slic Relations District Court

Sl:"T~

o~n:m 811m

To the Judge orille atxl\'c-nam~t.ll·uurt:

I hll\'C received from the Dcp3rtnlCnl of s..'I\:ial Scn.. iC'~s notice of intenl to suspt:nd ur lU refuse 10 renew 01> dri\"cr"s license li.11" l'8illlre lil POl)child support or failure to comply with proc..:s~ relating to a patcmi~ or child support pNCe~ings. Accordingl).1 rcsrec.lfully request thai thecourt issue a restricted dr;\"I,~(~ licenM:. for good cause shown. for the followin~ purpo!\l:s:

( J tTavel to or from Rl) place ofemployment.I I lra\c110 and fmm V ..\SAP.I J travel during OJ}' hours ofcmplo)nh:nt. bccauSl: Ihc operation ofa motor \chic1c is ncl.'CSSUl') hl m) employment dc~ribcd belo\\.

l:MPlOnK :o.. .... \U. AM) WORK LO('ATlO",

HOVRS FDA Tlv•.\"E! TO .... "'0 t 11.0"1 woa),.

( I Ira\Cel fa and from school. (I unllerstand that I mlL~t provide proper ",Tinen v~rincation to lhe coun lhal I am ~nrolled in a conlinuing.program ofeducation.'

' ..~X:REQl:FS1H) I)ATES ASDTlMf$ fOR TRAHL TO ... "'D FRO'" SOlDOI

( J medically fk.-cessal') tnl.\d lor { I m~ ( I c1derl~ parenl ( I ('tC:rson n:sidill~ in m) hou~hl1ld_ (I understand thaI I musl pr\l\"ide \\rincn\'criticalion fmOl a licensed heahh pmfc:ssional nfdlt= need for such lr.t\'elli.lr an c:1dl:r1~ parenl or household m,mbcr. J

:o..A\I~.o\:<-O l()C.·...'lJO~ /'lI.OVIUUt. ur Mum, ,"'1. sun I( t:\

l I t(3\,('1 necessary to transport a minor c.:hilJ under m) ..:are ( I to and from school ( I to and fwm day' "'are and/orI J 10 and from facilities housing. medical SC~ icc proo,'ider,

' .NAME .... :0..1) I.OC,o\T10:o.. Of S("H()(}(.D.... Y C-\Jl.E \flDK AI. SoHI.\·Ift:S r'RovlllFR

I J mm.:1 tu ami Hum \:uurt-tlrlJcrcll \·isitatic.ln Wlth my child or l;hildren.. .,

........~ .. ; .~A~ILlSl .... !I;O LOC"'TIO~ OF flllLD Oll. CHlI.ORF."

( 1 travc:1 to and from appuintments \~ ith my probal~n onicer...: ~~'

..!.: ,.• .-,~ .S"'''l~ ."l> Loc....no' OF ra.o&....no' t:'Tm'

( J travel to and from programs required by court llr as conditions of prohat ion.

( I U'a\'CllO and Irom a plact' of religious pla..::c of\\orship.

'\.MI' .\:0.;1) to(· \. rkY.'> Of Pl. ....l·( Of 1lJ:t.l(;tOCS \\OIl5UII'

UOl·Hnf.D D.\Y 10\'"1: D...Y PUt \\T(;I" A~O11\.1.( FOR TIl.-\o, fl.lO ....~{) FRO~' PI,An or Rft.IGlOI S WORSllIr

I 1 tra\'c1 to and from appointments ilppr{l\"cc.l b~ the Di\'isioll of Child Support Enforcement l.lt'the Department of Social Services ll.s <I.

requirement tlf participation in a l;ourt-urdcrcd iIJlensi\~ case monitoring program lllr c.:hild :iUpllOrl which I \\ ill ha\t' (l1l"M1f oflhcappointm~1l1.indudin~ \\Tillen pn)(lr Uflhc dati: and time oft~ uppoimment.

I I tra\cl to and from jail 10 ~,,'e a,inil ~nlcnc( thai is to be ~"ed on w~kenJ.sor un non,,~oJlscclJli\cdot~· ...

lundenaand IhntlnL' CHUrt muy decide nmlo is'Hle a r..·~tricled dri\'cr"s lic("n,c. lunJcrstand that a restricted Jri\'cr"s licl..'nsc will n{lt permitme to operate a commercial motor "·chidt'. I und~rstand th::lt ::I restricted dri\~r:; liccn~ will nOI authori7c \'isilation of m\ child or childrt::nifo,'isilation is olherwise prohihilOO. -

DAn:

Date

Noncustodial Parem Name

Noncustodial Parent Address

l'oncustodial Parent Address

COMMUNWEAL III Of VIKlil"IAOEI'AKTMENT OF SOCIAL SERVICES

DIVISION Of ('1111.[) SUPPORT I"lFORCEMDIlPAYME'NT AGREEMENT -1)OSl-DMV Suspc:nsion

Driver's License Sus~nsian

DCSE Case Number

DCSE Case Number

DCSE Case Number

DCSE Case l\umber

I acknowledge that as of .20_.1 owe a total child suppon arrearage in the amount ofS for theabove cas('(s). Because of this arrearage. the Virginia Division of Child Suppon Enforcement (DCSE) has requested that the VirginiaDepanment arMotor Vehicles (DMV) suspend my driver's license for failure to pay child support. I am enlering into this agreemenlvoluntarily. If 1comply with the terms of this agreement. DCSE will report to DMV that we have entered into an agreement meetingthe tenns of Va. Code § 46.2-320 so thal m)" driver's license will no longer be suspended for the nonpa)"mem of child support. Iunderstand that my license may be suspended for other reasons, and if that is true. Ihis agreemenl will have no bearing on an} othersuch suspension(s).

I have entered into Payment Agreement(s) including this one. Upon the exe~ution of this agreement, I am making a lumpsum payment in the amount of $__ . .. to OCSE. In addition, I agree to pay S per month toward the arrearagebalance setlonh above. This paymem amount may be grealer than the lotal of any previously-ordered arrearage paymenl(s). I alsoagree to pay when due all current support ordered no", or in the future in the case(s) listed above. I understand that interest willcontinue to accrue on all arrearage balances until paid in full. I understand and agree thai if I fail to make any payment required bythis agreement on or before the date it is due. DCSE may take immediate steps. without any funher notice to me, to request that OMVre~suspend my driver's license. IfDMV re-suspends In}' driver's lic~nse,1 understand that DMV will not reinstate nl)'license untilOCSE notifies DMV that I have entered into fl new agreement. I funher understand thai in addition to payments required under the:tenns of this agreement to be made to DCSE. DMV may also require the payment of fees and costs. including reinstatement fees.

1underSland that Ihis agreemel1l dOl:s not preclude OC"SE from using other legal means 1O collect any current SUPptxt or arrearagtc'sthai lowe, including, but not limited to, interception of Ill)' state and federal income tax refunds.

If I have more than one case. I understand that DCSE will allocate all child suppon payments according to federal and state law.understand that I cannot designate how 01)' paymenls will be allocated or distributed.

1 make this agreement with full knowledge of my rights and duties under Virginia law.

This agreement between OCSE and the noncustodial parent is made and efl"eclive this day of .' 10 _.

;;:-----;:-,-c-~:-:.---..------­Signature of Noncustodial Parent

Name ofOCSE Representative

Signature of DCSE Representative

Address

APKS ~Ol- 6/11

COMMONWEALTH OF VIRGINIADEPARTMENT OF SOCIAL SERVICES

DIVISION OF CHILD SUPPORT ENFORCEMENT

IMPORTANT NOTICE ABOUT CHILD SUPPORT

DO CASE. n SIOOIAL PARENT'S NAME

Dear:

This notice provides important infonnation about laws that may aFfect you.

Child support is very important, If you are paying child support regularly. thank you for meeting thatresponsibility to your children.

If you owe support and are not paying the support. state and rederal laws allow the Division of ChildSupport Enforcemet1l (DCSE) and the courts to collect the money you owe. Some ways we collect support areby

having your employer withhold support from your wages;issuing liens and orders to withhold money in bank accounts and other financial institutionaccounts:seizing and selling your property;intercepting state and federal payments and refunds due you:reporting your past due support to consumer reporting agencies;requesting the Secretary of State to dt:ny. revoke. restrict or limit your passport, andhaving the Virginia Employment Commission withhold support from yourunemployment beneIits.

10 additioo. ifyou owe at least $5.000 or are behind at least three months in your support payments or youfail to respond to a subpoena. summons or warrant issued by DCSE. DCSE may take the following actions:

Ask the Department of Motor Vehicles (DMV) to suspend or refuse to renew your driver's license.The DMV will not return) our driver's license until DCSE tells the DMV that you have: 1) paid

your past due :;upport in full. or 2) made a substantial payment and t:l1ll:n.-::u into atl Ut;n';\,;IllCIl1 with

DCSE 10 pay your remaining past due support. or 3) complied with the subpoena. summons orwarrant.

Ask the courts to require you to turn in any certificate, registration, or other business, trade,professional. occupational or recreational license (including hunting and fishing) issued to you.Courts will not order the licensing agency to reissue your license until DCSE tells the court thatyou have: 1) paid your past due support in full. or 2) made a substantial payment and entered intoan agreement with DCSE to pay your remaining past due support.

PAGES I OF 2

·\PEeS·IOIl R". 01/12

The DCSE may charge fees for the following aClions it lakes:

Intercepting federal payments and refunds:Using a private process server 10 serve nOlices on )'ou:Using the services of an attorney for court enforcement actions when the court rules in DCS['sfavor, andSeizing and selling your property to pay pasl due support you owe,

Ifyour address or telephone number changes. you are required by law to send DCSE written notice ofyournew address or telephone number within 30 days ofthe change, Send your address or telephone num ber changeto the district office listed at the top of this notice,

If you believe your child support order needs reviewing and it has been at least three (3) years since yourlast re-vie"" or if ),ou can show a material change in circumstances. mail a written request to the District OtTicelisted at the top of this notice, The following are examples ofa material change in circumstances:

A change of 25 percent in the income of either party:A change in dependenl care, health insurance or medical expenses. andA change in the number of dependents in the current case for which either party is legallyresponsible,

OCSE will a"k you to provide intbnnalion about )'our current income. The review may resuh in anincrease. decrease or no change in your curren( suppon order. It will not change the amount of past due supportyou owe.

The Commonwealth charges you interest on your past due support at the judgmenl rate <Slablished by statelaw on support orders issued in Virginia. This rate is currentl)' six percent annually. The Virginia GeneralAssembly sels Ihis rate and il may change every year, II'the support order was issued in anolher state. Virginiacharges imerest on your past due support as specified in your support order. or ifnot specified, in accordancewith the law of the issuing state,

To avoid collection actions. pay your child support, II'you owe past due support, PA Y IT NOW. If youcannOI pay all of Ihe past due support al once. contact Ihe District Omce lisled at the top or this notice,immediately, 10 ".... ork Olll a payment plan.

I'A YME"T INSTRUCTIONS

Mail a personal check. cashiers' check or money order for the amount you owe. Make the paymem payableto the Treasurer of Virginia. Include your social security number on the payonem. Mail the payonenlimmediately to:

DIVISION OF CHILD SUPPORT ENFORCEMEI'TPOBOX 570

RICHMOND VA 23218-0570

DO NOT INCLUDE CORRESPONDENCE WITH YOUR PA YMENT. Mail correspondence to the DistrictOmce listed at the top of this notice.

(fyour ease closes wilh DCSE, Ihis will nollerminale existing child or spousal supporl order. It will notafTect any arrears lhat have accrued under your orders.

NOTICE: Section 7 oflhe Privacy Act (5 L:SC 552a) and section 466(3)( 13> of the Social Security Act l42 LiSC666(aX 13)] require all individuals subject to child suppol1 orders to provide their social security numbers. These:numbers will be kept in the case rcc-ords. and will only be used to locate individuals for purposes of establishingpaternity and establishing. modifying. and enforcing suppoI1 obligations.

~A(jES 2 01- 2 AI'ITS-IOU Rc\.OIl12

Part 1 - There are strict confidentiality rules regarding the disclosure of information available through thems.-This section is to verify that the information is beinll reQuested for a reason authorized by fedecallaw.

Virginia Department of Social ServicesDivision of Child Support Enforcement

APPLICATION FOR LOCATION INFORMATION

Purpose of Request [To be completed by requestor]A, (42 USC § 653J

Establishing parentage• Establishing. modifying, or enforcing a child support order

International child support enforcementChild welfare permanency planning

e, 142 USC, 6631• Making or enforcing a child custody or visitation determination• Parental Kidnaooino

,i

IIiIj

!

Moil Request toVll'llnll State Plrent ~atorService

Divi!ion of Cbild Support Enforcement801 EaJt Main Slreet, 12tb FloorRicbIBOOd, VA 23219-2901

DATE of Request _

DATE Returned

Port 2 - Then orl strict confidentiality rulls regarding who hos oceess to Infonnotlonavailable through the FPLS. This section is to verify that the person requesting theInformation Is authorized to do so by feclerdl low. Your signature certifies that the locationinformation requested will be used ONLY for the DUnlose checked.Requeatar {To be completed by ,.qUGlitorj

Custodial parent (A. only)• Private attorney who represents child or custodial parent (A. only)

Attorney representing a State CourtLDSS staffAttorney representing tne United States (8. only)

Part 3 - Person about whom information Is bel

i, .

FuD Name • Adult • Child (8. only)Date ofBirth Gender M or F Social Security # _Additional Inronnation. e. "' F.SlCAR' dataPrlnted Name of RequestorSignature ofRequestorAddress ofRequestor

FOR OFFICE USE ONLYRequest is not made for an authorized purpose, service cannot be provided.Request is not made by an authorized person, service cannot be provided.SSN verified. but no infonnalion was found for individual named,SSN was not verified, and no information was found for individual named.Information was found for individual named and is attached.

The infonnation provided below was obtained from the Federal Parent Locator Service (FPLS). It is the mostRecent Infomation available through that source and may not be the actual location of the person you inquiredabout. This information is strictly confidential and may only be used for the purpose for which it wasrequested.

Sedioa 7 oflbe Privacy Act (5 USC 552a) and .ection 466(aXI3) of the Social Security Act (42 USC 666(a)(13}1 reqUire allindividuals subJed to cblld support orders to provide tbeir soclalseeurily numbers. Tbese numbe,. wiD be kept in lbe ca.erecords, lad will only be used to locate individuals for purpo'" of establishing paternity and establlsblng, modifying, andcoforclng .upport oblta.tioDI.

DCSEP·8255/18I07

Division ofChild Support EnforcementInterstate and Non IV-D Operations SectionATTN: Ms. Paulette Rainey80 I East Main Street, 12th FloorRichmond, VA 23219-2901

Re: Federal Parent Locator Service Request

Dear Ms. Rainey:

Please request from the Federal Parent Locator Services (FPLS) the most recenthome address and place of employment for the following individual:

Name: _

Social security number: _

Date of birth: _

Other information: _

This request is made pursuant to Title 42 U.S.C. § 663 and is for the purpose ofmaking or enforcing a child custody or visitation determination. Please send therequested information to [INSERT JUDGES ADDRESS]

This case has been continued to , therefore, I request that yousubmit this request to FPLS and forward their response as quickly as possible.

Sincerely,

Judge

ICMP LOCALITY OFFICE THAT HANDLES

ALEXANDRIA ARLINGTON (F4)

AUGUSTA FISHERSVILLE (C2)

BEDFORD LYNCHBURG (LO)

CAMPBELL LYNCHBURG (LO)

CULPEPER CHARLOTTESVILLE (COl

FAIRFAX FAIRFAX (FOI

FAUQUIER M ANASSAS IF1)

FRANKLIN CiTY SUFFOLK (Pl)

FRANKLIN COUNTY DANVI LLE ILl)

FREDERICK COUNTY WINCHESTER (F2)

HAMPTON HAMPTON (HO)

HENRY DANVILLE (Ll)

ISLE OF WIGHT SUFFLOK IPll

NEWPORT NEWS NEWPORT NEWS (NO)

ORANGE CHARLOTTESVILLE (CO)

PETERSBURG PETERSBURG IPO)

PRINCE GEORGE PETERSBURG (PO)

RICHMOND RICHMOND (00)

ROANOKE ROANOKE IRO)

ROANOKE COUNTY ROANOKE (RO)

RUSSELL ABINGDON IAOI

SALEM ROANOKE (RO)

SOUTHAMPTON SUFFOLK (Pl)

SPOTSYLVANIA FREDERICKSBURG (Cl)

STAUNTON FISHERSVILLE (C21

SUFFOLK SUFFOLK (Pll

VIRGINIA BEACH VIRGINIA BEACH (BO)

WARREN WINCHESTER {F21

WINCHESTER WINCHESTER (F2)

DIR£CTIOi\S FOR Ill' All! '\(; SI \1\1 ,\R.\" CASt. ,\C("Ol',T ST \ TE\IE'\T

fOR TH.E PERiOD. LiSI'> th~ d.llC r:mgc for wh:.:h lh:: summary \....:lS s~kCh.. d.

PARTICIPANT: Lists the nJI1" and ,\PEeS YIPI number of the CP J"d :-:CP ""Jehe,\ to the ca"

FREQU[};CY A\tOl""ST hkntl:id i:l~ .lbll::;JIi0Ii J.:~:'J";:': for .1;: SUppIJrt :;l'~s (dH1J,spL'l:..sc.n~J:":J.I.nuS..:.(h:)

TOTAL 0.-\ L ThiS is Ihl,." cJ1Jn.:e m;IU5IVl' or all ar:'~:tr5 subaccounts for Jli support t:."P~s

including Out of St:uc J.;reJ:" bJt:1nces (OSAsub:1cco;.mt). This docs not includ~

cunent SUpr~·Hi.

CHARGED DATE: IdC'nliti~s :1\;.' .j;:t~ of th<: nt:xt ..:hJrgc:

ORDER START DATE: Slates lhe slart dale of the acti'e currenl suppa" oblig'tion

DT PST:

ADJ:

ORD AMT:

p,~Y:-1E:-'"T:

CSUP BAL

Identllir:s ::1-': ;b:c n.n,~ adjtlstm::nt. order amuunt and'or p:lY:1~cnt tr.1ns:1Llion($)

occunco.!, In m'Jllrh <.by yCJr lOIT:"'.Jt

Idl.·ntilics t~:l: an adjU5tn~':lit c..:.:urrcJ on lh~ d.1te ret:;.·cte:li :n the DT PSTcl)lu01:'. b:·.l en:: kl1er code .1) lisled bc::low:

:\ ;\rr~.Jrs subJ(::ounto [3i)fh Jl'Tc:lrS Jnd ~ur:ent support SUb.1C::Ol:nt:i

C Current Suppor. Subaccountl. Inh:~C:s: SubJc;:ountF. f :::c::s SubJccou:n~I ~hl!tipk Suc.Jccounts, .loy combin:uicn of current support

J;TCJ.IS. il~tere~:, and feesTh~ speciti-.: JdJuslment dCIJil ':Jnnol be s~en on thi~ !i:umrn:lry !>t~ft'rnen[.

ho\...·e ...cr, th~ o1n..:ctc:d b.l!Jn-.:c: column \...·m reflect an incr::Jsc:: or dc::~rr3sc

This coluw.n r;::prcsc:nls the amount ch3rged to curn:nt support on (h~ d:ltereflected inl!:(: DT PST colu.'1"U1. If an order is modified, the adjustedfigure is re:~ort:.;'d in this .;oli..:mn on the date it was ente:rec.

Lists the: pJyn,;~nls made to {~: CJse on the dare the distribution occurred.

This d3te IS n:t!rcled 10 thl" DT PST column. The code: that folkJWSIdentifies ~hc $P~':!:-:( suc3,::ccar.1 thai th<: p:lynlent dlSttibtl:cd thmu£h.1'h< colic CC:-.:lltll'P.$ ,Jr,,: ::i': salr:c :lS the adjustmcn: codes ~nd ar<: as follows.

A ;\:-:·::aH sU·~J':':lJur:.;

l3 lhlth 3rr(.:]::; 3:<.1 (tJrre:H support subaCCO\ml

C. ClltiCnt SUPpI)rt SLlOJ\:countI. 11~iereS! SUDJ,coc:~t

F. t· ::e:";) subJcco~nt\1. ~ll.:!tii''' sl.,;:a.:.:ot,;r:.ts. aay combinai;on of current support.

:l~r;:Jrs. 1:1lcr~$f" 3:1J fc~s

Re:ports lhe: bJ!Jn\:~ 0:" th~ ':U;T~nt support sl.;baccount for the date lIsted In theDT PST column. This bJ.b.nce is in ascending order. A gap in the dolte r.mgc

means cur:-cn: suppl1n IS p:lId In full until the next chJrge rericd

f- I .f 2.

ARRSBAL:

NTBAL:

FEE BAL:

TOT BAL:

Reports (h~ bi),lance of the J.rrears subaccount(s) for [he dJ.te Iis[cl.1 In

the DT PST column. This balance is in ascending ord<r. A gap in IhedJt~ r:mge means the: balance went to zero.

Reports tb~ balJnce of the interest 5ubi1ccount(s) for lhe date listed in theDT PST column. This balance is in ascending order. A gap in the date~nge means the balance went 10 zero

Reports the balance of the fee subaccount(s) for the daE< listed in theDT PST column. This balance is in ascending order. A gap in the da<erange m~3ns the balance went to zero. This fee column is for the AFIIfee only, which is the fee charged 10 the Stale for a collection procedure,then passed on to the NCP. This fee balance does NOT include Blood Testor Legal Fees

Li:m the:: total bJlJnce for the arrears subaccounts for 311 support (yp~s. Thisb:llanc~ is :1 total for the date IiSlcd in the DT PST column of the arte:us.interest. and fee balances. It does not inetude any cunent support due Jnddocs not include any arrears due in the Out of Stat< Arrears subaccount (OSA)

NOTES

I. This is ;), combined Summ.J.ry Case Account Statement for ALL support types in aspt:cific CJSC.

A. ChildB. SpousalC. Medical, payable to CPO. Medical, payable to the StateE. Misc. fees including blood test and legalF. Out of State Debt 10 State or State owed medical

2. The summary statement is chronologically ascending and read from left to right.(It's read easiest by placing a ruler or envelope under the most current date,

then reading across the page for the most current status)

3. The taUI amount owed on 3. specific C3.se can be determined by adding currene support andtotal b3.l3.nce from the most current DT PST line.

fl- z...·f L

EVIDENCE ORDER (SUPPORT)COMMONWEALTH OF VIRGINIA

Case No .

DCSE No....•.........•......•.•...

______________ County Juvenile and Domestic Relations District Court

DCSEexrel.

v.PETITIONER RESPONDENT

This matter is before the Court upon the filing ofa written petition or motion for child support and proper notice hasbeen given to all proper and necessary parties. All provisions afthe Juvenile and Domestic Relations District Court law, and theamendments thereto, have been duly complied with in assuming jurisdiction and the Coun finds that this support matter is withinthe jurisdiction of this Court.

In order for the Court to make an appropriate finding as required by law, the Court needs certain evidence to be broughtbefore it, therefore

The Court hereby ORDERS that the parties bring evidence ofthe following to the next hearing:

1. All evidence of income from all sources as defined in §20-1 08.2(C), including but not limited topay stubs from the last 3 months, 20_ W-2 or 1099 tax fonns and 20_ Federal Tax Returns andall attached schedules.

2. Employment related childcare cost for the past 12 months for children subject to this order.

3. Cost of health and dental insurance for children only subject to this order (premium costs forfamily, single, single plus one).

4. Other natural or adopted minor children living in the home of one ofthe parties.

5. Coun order or wrinen agreement and proof of payment of support for other natural or adoptedminor children not in the home of one the parties.

6. If unemployed, all efforts made to find employment since last employe~ including but not limitedto copies of resume, applications. and a daily log of all efforts taken to find gainful employment

7. Oth." ~

NOTICE

ANY PERSON WHO FAILS TO COMPLY WITH THIS ORDER MAY BEPROCEEDED AGAINST FOR CONTEMPT OF COURT PURSUANT TO

VIRGINIA CODE §18.2-465(5).

Endorsements waived pursuant to Supreme Court Rule 1:13 and this Order issued to:

NEXT COURT DATE: .

DATE JUDGE