The notice shall be substantially in the following form:

NOTICE OF ACTION AGAINST LICENSE

Name and address:

Date:

Case No:

Social Security No:

Family Court of ________ County, West Virginia

Section 1.

G The Bureau for Child Support Enforcement has determined that you have failed to comply with an order to pay child support and that the amount you owe equals six months' child support or more. The amount you owe is calculated to be $____________ as of the ______ day of ____________, _________.

G The Bureau for Child Support Enforcement has determined that you have failed to comply with a medical support order for a period of six months. The amount you owe is calculated to be $___________ as of the _______ day of ______________, __________.

G The Bureau for Child Support Enforcement has determined that you have failed to comply with a medical support order requiring you to obtain health insurance for your child or children.

G The Bureau for Child Support Enforcement has determined that you have failed to comply with a subpoena or warrant relating to a paternity or child support proceeding.

Section 2.

Under West Virginia law, your failure to comply as described in Section 1 may result in an action against certain licenses issued to you by the State of West Virginia. Action may be taken against a driver's license, a recreational license such as a hunting and fishing license and a professional or occupational license necessary for you to work. An application for a license may be denied. A renewal of a license may be refused. A license which you currently hold may be suspended or restricted in its use.

The Bureau for Child Support Enforcement has determined that you are a current license holder, have applied for or are likely to apply for the following license or licenses:

To avoid an action against your licenses, check which of the following actions you will take:

G I want to pay in full the overdue amount I owe as child support. I am enclosing a check or money order in the amount of $ ___________.

G I want to pay in full the amount I owe as medical support. I am enclosing a check or money order in the amount of $ ____________.

G I am requesting a meeting with a representative of the Bureau for Child Support Enforcement to arrange a payment plan that will allow me to make my current payments as they become due and to pay on the arrearage I owe or to otherwise bring me into compliance with current support orders.

G I am requesting a hearing before the family judge to contest an action against my licenses. Please serve me with any petition filed and provide me with notice of the time and place of the hearing.

Signed _____________________________ Date: _____________

Section 3.

You must check the appropriate box or boxes in Section 2, sign your name and mail this form to the Bureau for Child Support Enforcement before the______ day of ___________, _______. Otherwise, the Bureau for Child Support Enforcement may begin an action against your licenses in the Family Court without further notice to you. Mail this form to the following address: