Fill and Sign the How to Complete an Income Withholding for Support Order Form

Document Tracking Identifier ______ _____________________ OMB 0970 -0154 June 2015 Form 3N051 INCOME WITHHOLDING FOR SUPPORT  ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)  AMENDED IWO  O NE -TIME ORDER /NOTICE FOR LUMP SUM PAYMENT  TERMINATION of IWO Date: ______ _______ 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 instruct ions www.acf.hhs.gov/programs/css/resource/income-withholding -for -support -instructions ). If you receive this document from someone other than a s tate or tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory Texas ____ ____ Remittance I D (include w/ payment) __ ______ __ ___ _____ __________ ___________ City/County/Dist./Tribe __ ___________ ____ _ Order ID ________ __________________________________ __________________ Private Individual/Entity _______ _________________________ CSE Agency Case I D ________ ________________ _____________ _____________ _ _____________________________ _______________________ Employer /Income Withholder’s Name _______ _____________________________________________ Employer /Income Withholder’s Address ____________________________________________________ ____________________________________________________ _______________________________________ _____________ ____________________________________________________ Employ er /Income Withholder’s F EIN RE: __________________________________________________________ Employee/Obligor’s Name (Last, First, Middle) __________________________________________________________ Employee/Obligor’s Social Security Number __________________________________________________________ Custodial Party/Obligee's Name (Last, First, M iddle) Child(ren)'s Name (s) (Last, First, M iddle) Child(ren)’s Birth Date(s) __________________________ ____________________ __________________________ ____________________ __________________________ ____________________ __________________________ ____________________ __________________________ ____________________ __________________________ ____________________ ORDER INFORMATION: This document is based on the support or withholding order from _____ (State/Tribe). 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 child support - Arrears greater than 12 weeks?  Y es  N o $ ______ Per ______ current cash medical support $ ______ Per ______ past -due cash medical support $(leave blank) Per (leave blank ) current spousal support $(leave blank) Per (leave blank ) past -due spousal support $(leave blank) Per (leave blank ) other (must specify) ___________________________________________________________. for a Total Amount to Withhold of $______ p er ______. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with t he 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 S um Payment : Do not stop any existing IWO unless you receive a termination order REMITTANCE INFORMATION: If the employee/obligor’s principal place of employment is Texas, you must begin withholding no later than the first pay period that occurs zero (immediately) days after the date of delivery . Send payment within two working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 50% of disposable income. If the obligor is a non-employee, obtain withholding limits from Supplemental Inform ation on page 3. If the employee/obligor’s principal place of employment is not Texas , 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. OMB Expiration Date – 0 7/31/201 7. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. June 2015 Form 3N051 Employer’s Name: ___________________________________________ Employer FEIN: ___________________________________________ Employee/Obligor’s Name: ____________________________________ SSN: ____________________________________________________ CSE Agency Case Identifier: ___________________________________ Order Identifier: ______ _____________________________________ For electronic payment requirements and centralized payment collection and disbursement facility information ( State Disbursment Unit [SDU]), see www.acf.hhs.gov/programs/css/employers/electronic -payments . Include the Remittance I D with the payment and if necessary this FIPS code: ______ Remit payment to At: □ Return to Sender [Completed by Employer/Income Withholder]. 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 a n SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if Required by State or Tribal law) : P rint Name of Judge/Issuing Official: ________________________ Title of Judge/ Issuing Official: ________________________ Date of Signature ________ _____________________________ If the employee/obligor works in a s tate or for a tribe that is different from the s tate or tribe 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 TO 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: Withholding 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 t ribal 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 sende r. Exception: If this IWO was sent by a c ourt, attorney, or p rivate individual/ entity and the initial order was entered before January 1, 1994 or the order was issued by a t ribal 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 must comply with the law of the s tate (or tribal 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 there 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 payment of any past -due support. Follow the state or t ribal law/procedure of the employee/obligor’s principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a s tate 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 sende r. 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 s tate or tribal law/procedure. ________________________________________________________________________________________________________________________________ Anti -discrimination: You are subject to a fine determined under s tate 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 . _________________ _______________________________________________________________________________________________________________ OMB 0970-0154 June 2015 Form 3N051 Employer’s Name: ___________________________________________ Employer FEIN: ___________________________________________ Employee/Obligor’s Name: ____________________________________ SSN: ____________________________________________________ CSE Agency Case Identifier: ___________________________________ Order Identifier: ______________ _____________________________ Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 USC §1673 (b)); or 2) the amounts allowed by the s tate 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 making mandatory deductions such as: s tate, federal, local taxes ; Social Security taxes ; statutory pension contributions; and Medicare taxes. The federal 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 s tate or tribe , you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing t ribe. For tribal employers/income withholders who receive a state IWO, you may not withhold more than the limit set by tribal law. Depending upon applicable state or tri bal law, you may need to consider the 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 weeks, then the e mployer should calculate the CCPA limit using the lower percentage. Supplemental information: Non -employee s’ withholding limitations are the same as that for employees unde r Texas Family Code ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ IMPORT ANT: The person completing this form is advised that the information may be shared with the employee/obligor. 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 a gency and/or the sender by returning this form to the address listed in the c ontact 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: __ _______________________________________________________________________________ _____________________________________________________________________________ _____________ ____ F inal payment date to SDU/ tribal Payee: ________________________________________ Final payment amount: ______________________ New employer's name: __________________________________________________________________________________________ ________________ New employer's address: _________ _______________ _______________________________________ ________________________________ _______ _________ _________________________________________________________________________________________ ____ CONTACT INFORMATION To Employer /Income Withholder : If you have any questions, contact by phone at , by fax at , by e-mail or website at www.employer. texasattorneygeneral.gov Send termination/income status notice and other correspondence to: Office of the Attorney General Child Support Division Central File Maintenance P O Box 12048 Austin, TX 78711 -2048 To Employee/ Obligor: If the employee/obligor has questions, contact by phone at , by fax at , by e-mail or website at http://texasattorneygeneral.gov/cs/ The Paperwork Reduction Act of 1995 This information collection and associated response are conducted in accordance with 45CFR 303.100 of the Child Support Enforcement Program. This form is designed to provide uniformity and standardization. Public reporting burden for this collection of information is estimat ed to average 5 minutes 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 re quired to respond to, a collection of information unless it displays a currently valid OMB control number.