Form PS–03 

Rev. 4/08

Request for Contempt Hearing

Case Number: (Use the # on your Child
Support Order)

In the                                                                                                                         Court of (county):                                                                                                         County, Alabama

Plaintiff’s First and Last Name
(the person listed as Plaintiff on any previous Order in this case)

Defendant’s First and Last Name
(the other parent)

v.

If the other parent has disobeyed a court order related to the children, such as an order to pay support, pay for medical
bills, provide insurance, or an order related to visitation, you may ask for a contempt hearing. At the hearing, a judge
will listen to the evidence that you and the other parent provide. If the Court decides that the other parent purposely
disobeyed a court order, the judge may make new orders. The judge may also fine or send that person to jail.
q  The person asking for a hearing is the (check one):   Plaintiff    Defendant

Name:                                                                                                                                               Phone #:                                                 

Address:                                                                                                                                                                                                            

street address 

city

state 

zip

w List the date and place where your current child support order was made:

Date:                                                         County and State:                                                                                                     
List the court case number of your current order (case #):                                                                                                          

e What does your court order tell the other parent to do? (Check all that apply):

 To pay child support. Amount: $                                               per                                                                                           
 To pay some or all of the medical and dental expenses for the child/ren listed in the Order.
  To allow visitation with the child/ren.
  Other (explain):                                                                                                                                        
  Other (explain):                                                                                                                                        

r List the court order(s) the other parent has disobeyed. (Check all that apply):

 The other parent owes back child support.  Amount: $                                                                    , plus interest.
 The other parent has not paid his/her share of the child/ren’s medical/dental  expenses.

Amount owed: $                                                                              

  The other parent has not provided health insurance for the children.
  The other parent has not allowed visitation with the child/ren.
  Other (explain):                                                                                                                                        
  Other (explain):                                                                                                                                        
t Other parent’s address:                                                                                                                                                                    
Other parent’s phone #:                                                                                                                                                                              
y What are you asking the court to do?                                                                                                                                     

                                                                                                                                                                                                                             

                                                                                                                                                                                                                             

I swear that that the information I have provided is true, and I ask the Court to set a date for a hearing on
this matter.

                                                                                                    
Print your name 

                                                                          
Sign here

                                               

Date

Notary fills out below—
Sworn to and subscribed before me, the undersigned authority,
                                                                      On this date:                                      

Print name of notary/clerk

                                                                                                                                  
  Notary signs here

(Notary’s seal here)

Rev. 4/08

© 2008 Alabama State Bar