For Clerk's Use Only Name of Person Filing: Mailing Address: City, State, and Zip Code: Daytime Phone Number: Evening Phone Number: _________________________________ ATLAS Number (if applicable): State Bar Number (if applicable): Self Petitioner Respondent Representing: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: (Name of Petitioner) AND REQUEST FOR RELEASE FROM ORDER OF ASSIGNMENT Employer / Payor (Name of Respondent) On ____________________________________________, this Court ordered an Assignment of the earnings (Date) or entitlements of ________________________________________________________________________. (Obligor) I am Obligor's employer / payor and allege that support payments submitted to the Support Payment Clearinghouse for the person named above have been returned to me. WHEREFORE, I request an Order releasing the employer / payor from the binding effect of the above-referenced Order of Assignment. I have read the foregoing document and the facts therein are true and correct to the best of my knowledge. I will immediately mail or deliver a copy of the Request to the Obligor. Date:________________________ _______________________________________ Employer / Payor STATE OF ARIZONA COUNTY OF MOHAVE ) )ss. ) SUBSCRIBED AND SWORN OR AFFIRMED AND ACKNOWLEDGED before me this _______________ day of _______________________, ___________ by ___________________________________ My Commission Expires: _________________ ______________________________ Notary Public / Deputy Clerk VIRLYNN TINNELL CLERK OF SUPERIOR COURT 6/13/2006 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com
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