Fill and Sign the Chapter 203 Mn Laws Form

LDSS -5038 (5/15) INCOME WITHHOLDING ORDER Court Information □ Family Court: _________________ County □ Supreme Court: _________________ County Order ID (Index/Docket Number) Employee/Obligor Information Name ( Last , First , Middle) Social Security Number - - Date of Birth (MM/DD/YYYY) / / Obligee Information Name ( Last , First , Middle) Mailing Address Part A Important N otice If you are issuing a Spousal Support Only Income Withholding Order, yo u must serve the completed LDSS -5038 as follows:  Part A: serve only upon the employer/income withholder.  Part B: serve upon all of the following: 1. employer/income withholder; 2. employee/obligor; and 3. obligee. Page intentionally left blank. Document Tracking I D_______________________ ___ _ OMB 0970 -0154 1 LDSS -5038 (5/15) INCOME WITHHOLDING FOR SUPPORT  ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)  AMENDED IWO  ONE -TIME ORDER/NOTICE FOR LUMP SUM PAYMENT  TERMINATION OF IWO Date: _____________________  Child Support Enforcement (CSE) Agency  Court  Attorney  Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions www.acf.hhs.gov/programs/css/resource/income -withholding -for -support -instruction s). If you receive this docu ment from someone other than a state or tribal CSE agency or a c ourt, a copy of the underlying order must be attached. State/Tribe/Territory _______________________ Remittance ID (include w/payment) _________________________ City/County/Dis t./Tribe _______________________ Order ID ________________________________ _______________ Private Individual/En tity ______________________ New York Case ID ________________________________ _______ ________________________________ _____________ RE: ________________________________ _____________ Employer/Income Withholder’s Name Employee/Obligor’s Name (Last, First, Middle) ________________________________ _____________ ________________________________ _____________ Employer/Income Withholder’s Address Employee/Obligor’s Social Security Number ________________________________ _____________ ________________________________ _____________ Custodial Party/ Obligee’s Name (Last, First, Middle) ________________________________ _____________ Employer/Income Withholder’s FEIN _______________ Child(ren)’s Name(s) (Last, First, Middle) Child(ren)’s Birth Date(s) ______________________________ ___________________ ______________________________ ___________________ ______________________________ ___________________ ______________________________ ___________________ ______________________________ ___________________ ______________________________ ___________________ ORDER INFORMATION : This document is based on the support or withholding order from New Yo rk State . You are required by law to deduct these amounts from the employee/obligor’s income until further notice. $ ____________ Per ______________ current child support $ ____________ Per _____________ past -due c hild support - Arrears greater than 12 weeks?  Yes No $ ____________ Per ______________ current cash medical support $ ____________ Per ______________ past -due cash medical support $ ____________ Per ______________ current spousal support $ ____________ Per ______________ past -due spousal support $ ____________ Per ______________ other ( must specify) ________________________________ _______________ for a Total Amount to Withhold of $ ____________ per __________________ . AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information . If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ _________ per weekly pay period $ __________ per semimonthly pay period (twice a month) $ _________ per biweekly pay period (every two weeks) $ __________ per monthly pay period $ _________ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. NOTE - Grayed out areas of this form are NOT applicable to spousal support only cases Part B Employer’s Name: __________________________ Employer FEIN: ________________________ Employee/Obligor’s Name: ______________ ___________ ____ SSN: ________________________ New York Case Identifier : ____________________ Order I dentifier : ________________________ OMB Expiration Date – 07/31/2017. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. 2 REMITTANCE INFORMATION : If the employee/obligor’s principal place of employment is New York State, you must begin withholding no later than the first pay period that occurs 14 days afte r the date of service of this notice. Send payment within 7 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, see Withholding Limits on page 3 . If the obligor is a non -employ ee, obtain withholding limits from Supplemental Information on page 3. If the employee/obligor’s principal place of employment is not New York State, obtain withholding limitations, time requirements, and any allowable employer fees at www.acf.hhs.gov/programs/css/resource/state -income -withholding -contacts -and -program -information for the employee/obligor’s principal place of employment. Include the Remittance ID , pay date and employee/obligor’s name on the payment.  Make payments payable in the name of the obligee identified on PART A .  Remit payment to obligee’s address identified on PART A . Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return th e IWO to the sender. Signature of Judge/Is suing Official (if required by State or Tribal Law): ________________________________ _________ Print Name of Judge/Issuing Official: ________________________________ ________________________________ ____ Title of Judge/Issuing Official: ________________________________ ________________________________ _________ Date of Signature: ________________________________ ________________________________ __________________ If t he employee/obligor works in a state or for a t ribe that is different from the state or t ribe that issued this order, a copy of this IWO must be provided to the employee/obligor.  If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State -specific contact and withholding information can be found on the Federal Employer Services website located at: www.acf.hhs.gov/programs/css/resource/state -income -withholding -contacts -and -program -information . Priority: W ithholding for support has priority over any other legal process under State law against the same income (42 USC §666(b)( 7)). If a f ederal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or tribal CSE agency, you may combine withheld amounts from more than one employee/obligor’s income in a single payment. You must, however, separately identify each employee/obligor’s portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a t ribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU ( e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a court, attorney, or private individual/ entity and the initial order was entered before January 1, 199 4 or the order was issued by a t rib al CSE agency, you must follow the “Remit payment to” instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor’s wages. You m ust comply with the law of the s tate ( or t ribal law if applicable) of the employee/obligor’s principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If t here is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to federal, state, or t ribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payme nt of any past -due support. Follow the s tate or t ribal law/procedure of the employee/obligor’s principal place of employment to determine the appropriate allocation method. Employer’s Name: __________________________ Employer FEIN: ________________________ Employee/Obligor’s Name: ______________ ___________ ____ SSN: ________________________ New York Case Identifier : ____________________ Order I dentifier : ________________________ IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. 3 Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor’s income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by state or t ribal law/procedure , together with interest and reasonable attorney’s fees. If you comply with this IWO you will not be subject to civil liability to any individual or agency for conduct in compliance with this IWO. In New York State, pursuant to Civil Practice Law and Rule s (CPLR) §5241, upon a finding by the Family Court that you failed to withhold or remit withholdings as directed in this IWO, the Court shall issue an order directing your compliance and may direct the payment of a civil penalty not to exceed $500 for the first instance and $1,000 per instance for the second and subsequent instances of noncompliance. Anti -discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. In New York State, pursuant to CPLR §5252, the court may direct a civil penalty not to exceed $500 for the first instance and $1,000 per instance for the second and subsequent instances of such discrimination. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 US C §1673(b) ); or 2) the amounts allowed by the state of the employee/obligor’s principal place of employment or tribal law if a tribal order (see Remittance Information ). Disposable income is the net income after mandatory deductions such as: state, federal, local taxes; Social Security taxes; statutory pension contribut ions; and Medicare taxes. The f ederal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - - to 55% and 65% - - if the arrears are greater than 12 weeks. If permitted by the state or t ribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For t ribal orders, you may not withhold more than the amounts allowe d under the law of the issuing tribe. For t ribal employers/in come withholders who receive a s tate IWO, you may not withhold more than the limit set by tribal law . Depending upon applicable state or t ribal law, y ou may need to consider amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 we eks, then the employer should calculate the CCPA limit using the lower percentage. Supplemental Information: (1) PART A of this form contains sensitive information and must be served only upon the employer/income withholder for purposes of processing the income withholding; PART B , which consists of 4 pages , must be served upon the employer/income withholder , employee/obligor, and obligee. (2) Priority of wit hholding pursuant to CPLR §5241 (h) is current support, followed by health insurance premiums, and then arrears payments. (3) If there are multiple IWOs against this employee/obligor, withhold the maximum amount permitted under the CCPA (see Withholding Limits, above ) and pay to each creditor the proportion thereof which such creditor’s claim bears to the combined total. (4) Where the income is compensation that is not paid or payable to the obligor for personal services, there is no limit to the amount you must withhold . (5) If the employee/obligor is reinstated or reem ployed within 90 days after termination, this IWO is still in effect. Employer’s Name: __________________________ Employer FEIN: ________________________ Employee/Obligor’s Name: ______________ ___________ ____ SSN: ________________________ New York Case Identifier : ____________________ Order Identifier: ________________________ 4 NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, you must promptly notify the CSE agency and/or the sender by returning this form t o the address listed in the Contact Information below :      This person has never worked for this employer nor received periodic income.   This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: ________________________________ _____ Last known phone number: _____________________ Last known address: ________________________________ ________________________________ ________________ ________________________________ ________________________________ ________________________________ _ Final payment date to Obligee / tribal payee :_________________ Final payment amount: _________________________ New employer’s name: ________________________________ ________________________________ _______________ New employer’s address: ________________________________ ________________________________ _____________ ________________________________ ________________________________ ________________________________ _ CONTACT INFORMATION: To Employer/Income Withholder: If you have questions, contac t __________ _____________________ (issuer name) by phone: _______________, by fax: ________________, by e -mail or website: ____ ____________________________. Send terminat ion/income status notice and other correspondence to :__________________________________________ ______________________________________________________ _____________________________ (i ssuer address). To Employee/Obligor: If the employee/obligor has questions, contac t ___________________________ (issuer name) by phone: _______________, by f ax: ________________, by e -mail or website:____ ____________________________. The Paperwork Reduction Act of 1995 This information collection and associated responses are conducted in accordance with 45 CFR 303.100 of th e Child Support Enforcement Program. This form is designed to provide uniformity and standardization. Public reporting burden for this collection of information is estimated to average 5 minute s per response for Non -IV-D CPs; 2 minutes per response for employers; 3 seconds for e -IWO employers, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.