"Date:_____________________
Escrow received from____________________ (referred to in this receipt as respondent) to assure the performance of the respondent's child support arrearage. The respondent shall appear for a hearing to show cause at ________(time) on _________(date) at the following address:
_______________________________________________________
_______________________________________________________
(Address to be furnished by respondent for receipt of notice.)
The hearing is for the respondent to answer an order to show cause. If the respondent is found to be in contempt, further proceedings related to the respondent's contempt may occur.
If the respondent fails to appear at the time and date listed above, fails to submit to the jurisdiction of the court, or fails to abide by the court's orders, the Court may direct the Clerk of the Circuit Court to distribute the escrow deposited with the Clerk of the Circuit Court under state and federal child support distribution laws.
If the respondent appears at the time and location indicated above and the Court determines the respondent owes an arrearage under the support order that is the basis of the order to show cause or owes any costs to the Court, the Court may direct the Clerk of the Circuit Court to distribute the escrow deposited with the Clerk of the Circuit Court under state and federal child support distribution laws.
By depositing the escrow amount and accepting this receipt, the recipient of this receipt waives a claim to the money following a Court order for distribution of child support.
Printed name and signature of person receiving escrow deposit: ______________________
Agency or department of person receiving escrow deposit: __________________________.".
IC 31-16-12-6.5