District No.

In the matter of .......... a child

........ Applicant

of .......

.......... Respondent

of ..........

WHEREAS ON THE APPLICATION OF THE .......... Health Board, made under section 18 (1) of the above-mentioned Act for an order with respect to the above-named child, the Court on the ... day of ...... 19... made a care order committing the child to the care of that health board,

AND WHEREAS in addition to making such order the court made a contribution order requiring the above-named *applicant *respondent to contribute to the health board the weekly sum of £... towards the cost of maintaining the child,

TAKE NOTICE that the applicant herein will apply at the sitting of the District Court to be held at ........ on the ... day of .... 19... at .... a.m./p.m. for an order under section 18 (8) of the Act *varying *discharging the said contribution order on the grounds that:—

Dated this ... day of ... 19....

Signed ..............

Applicant

To ..............

of .............

The above-named respondent.

* Delete words inapplicable