Fill and Sign the Instructions to Complete the Ordernotice to Withhold Income for Child Support Form

Instructions to compl ete the Orde r/No tice t o Withhold Income for Child Support or Notice of an Ord er to Withhold Income for Child Support The O rder/N otic e to Withhol d Income fo r C hild Sup port (O rder/Notic e) or N otice of an or der To Withho ld In come f or C hild Support (N otice) i s a sta ndar diz ed f orm use d for income w ithho ldin g in trib al, intrastat e an d in ters tate and int ergov ernme ntal ca ses. Pl eas e n ote t hat infor mation prov ided on t his for m may be share d with the obl igor. When com pleting the f orm, pleas e in clud e th e fo llow ing i nfor mation. The foll owing infor mation 1a -1g refers t o the gov ernment agen cy, non-gov ernmental entit y, or indiv idual com pleti ng and sendi ng this form t o the emplo yer. 1a. Check whether th is is an O rder/N otice to Withhol d In com e for C hild S upp ort or a N otice of an O rder t o Withho ld I ncome f or C hild Support. Attor ney s, i ndiv idual s, and non- gov ernm enta l en tities mu st sub mit a N otice of a n Order to Withh old and includ e a co py of th e inco me withh olding order unle ss, under a state' s law , an atto rney in th at state may issue a n inc ome withhold ing order/ not ice. I n tha t cas e, th e att orney may sub mit an O rder/N otice to Withhol d a nd in clu de a co py of th e s tate law authoriz ing the attor ney to i ssu e an inco me w ithh olding O rder/N otice. 1b. Check the appr opri ate stat us o f the O rder or N otice 1c. Date this form is co mpl eted or sign ed. 1d. Name o f the state, tr ibe or ter ritory send ing thi s for m. T his must b e a gov ernm enta l entity . 1e. Name o f the co unty , city, di stri ct, or r eservation se ndi ng th is Order or N otice, if appro priate. This mu st be a gov ern ment al entity . 1f. Check and ind icate t he n on-g overnment al e ntity or ind ividua l send ing this Order or N otice. Compl ete t his ite m only if a no n- gov ernme ntal ent ity or i ndiv idual is subm itting t his Order or N otice. 1g. Ident ifying case n umb er u sed by the en tity or indiv idual se nding t his Order or N otice. I n a I V-D cas e, th is mu st b e the IV- D c ase numb er. The foll owing infor mation in 2 and 3 refers to the oblig or, obligor' s em plo yer, and ca se ide ntifica tion. 2a. Employer/ Withhol der' s name. 2b-c. Employ er/ Withhol der' s mai ling addre ss, city, and sta te. (This may diff er fro m the Em ploy ee' s/O bligor' s work site.) 2d. Employ er/ Withhol der' s nine- digit fe dera l employ er ide ntification nu mber (if availa ble). Inc lude thre e-di git loc ation c ode . 3a. Employ ee' s/O bligor' s las t na me, fir st name, and middl e in itial. 3b. Employ ee' s/O bligor' s Social S ecuri ty Number (if know n). 3c. The case identif ier use d by the order issuin g s tate or tri be for record ing pay me nts. (Shou ld be the same a s #21. I n a IV-D case, thi s must be the IV-D case n umb er. 3d. Custod ial P arent' s last nam e, f irst n ame an d m iddl e initial (if know n) ORDER INFO RM ATION - The follo wing i nformati on in 4-1 4e refers t o the dollar amou nts tak en dire ctl y from the c hild su pport order . 4a. Name o f the state or trib e th at iss ued the sup port order. 5a-b. Dollar amo unt t o be withheld for pay me nt of curr ent chi ld support, tim e per iod that corr esp onds to t he a mount i n #6 a (s uch a s mont h, w eek, e tc.). 6a-b. Dollar amo unt t o be withheld for pay me nt of pa st-du e child s upport, time p eriod that c orres pond s to the amo unt in # 6a ( such as mont h, w eek, e tc.). 7a-b. Dollar amo unt t o be withheld for pay me nt of curr ent cash me dica l supp ort, i f ap propr iate, based on t he u nder lying o rder and the time peri od t hat corre spo nds to the amo unt in # 7a ( such a s mont h, w eek, e tc.). 8a-b. Dollar amo unt t o be withheld for pay me nt of pa st-du e cash medi cal su ppor t, if appr opri ate, bas ed o n the un derly ing ord er and t he time peri od t hat corre spo nds to the amo unt in # 8a ( such a s mont h, w eek, e tc.) 9a-b. Dollar amo unt t o be withheld for pay me nt of sp ous al sup port (ali mony ), i f ap propr iate, ba sed on t he u nder lying or der, tim e p eriod that corre spo nds to t he a mount in # 9a ( such a s month , week, etc.) 10a-b. Dollar amo unt t o be withheld for pay me nt of pa st-du e spou sal suppor t (al imony ), if appro priate, bas ed o n the un derly ing order, t ime period tha t co rres pond s to the amou nt i n #1 0a ( such a s mont h, w eek, et c.). 11a-b. Dollar amo unt t o be withheld for pay me nt of mi scellane ous obligatio ns, if a ppro priat e, b ased on t he u nder lying or der, time perio d that corre spo nds to t he a ount in #11 a (e. g., mont h, w eek, e tc.), and de scri ption of the miscellan eou s ob ligatio n. 12a. Total of 5 a, #6 a, # 7a, #8a, #9a , #10a , an d #1 1a. 12b. Time peri od t hat corre spo nds to the amo unt in # 12a ( e.g., mo nth). 13. Check thi s box if arrears grea ter than 12 w eek s. 14a. Amoun t an emp loyer shou ld w ithho ld i f the em ploy ee is pa id weekly . 14b. Amoun t an emp loyer shou ld w ithho ld i f the em ploy ee is pa id every tw o weeks. 14c. Amoun t an emp loyer shou ld w ithho ld i f the em ploy ee is pa id twice a m onth. 14d. Amoun t an emp loyer shou ld w ithho ld i f the em ploy ee is pa id once a m onth . REM ITTA NCE INFORM ATION: 15. The State i n which t his Order/ Notice is issue d. 16. Number of d ays within w hich the w ithhol ding mu st begi n pur suan t to t he issuin g s tate' s or t ribe' s law s/proc edur es. 17. The effect ive dat e of the income w ithhol din g. 18. Number of w orkin g day s w ithin which an emp loyer or other withhol der o f income mus t re mit amou nts w ithh eld pur suan t to t he issu ing state' s law . 19. The perce ntag e of inc ome tha t may be w ithh eld f rom the em ploy ee' s/obl igor s in come. For state order s, y ou may not w ithhold more than t he l esser o f: 1 0 the a mounts allowed by the F edera l Consu mer C redit Pr ote ction Ac t (15 U .S.C . §1673( b)); or 2) t he amo unts allow ed by the state o f the em ploy ee' s/obl igor' s prin cipal pla ce of em ploy ment. T he f eder al lim it a ppl ies to t he a ggreg ate disp osa ble weekly earnin gs (AD WE). AD WE is t he net i ncome left afte r mak ing man datory dedu ctions suc h as: s tate , fed eral, local taxes, So cia l Securi ty tax es, stat utory pe nsi on c ontri buti ons , an d M edicar e tax es. Page 1 o f 2 OM B 0970-0154 Page 2 of 2 OMB 0970-0154 For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 20. The state, tribe, or territory from which the Order or Notice is sent. 21. Name of the State Disbursement Unit, individual, tribunal/court, or tribal child support enforcement agency specified in th e underlying income withholding order to which payments are required to be sent. This form may not indicate a location other than that speci fied by an entity authorized under state or tribal law to issue an inco me withholding order. Please include the case identifier used to record payment (should be the same as 3c). In a IV-D case, this must be the IV-D case number. 22. Address of the State Disbursement Unit, tribunal/court, tribal child support enforcement agency, or individual identified i n #21. This information is shared with the obligor. Be sure to safeguard confidential addresses. Complete only for EFT/EDI transmission. 23a. Telephone number of contact to provide EFT/EDI instructions. 23b. Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characte rs that identify the state, county or tribe. It is seven characters when it identifies the state, county, and a location within the county. It is necessary for centralized collections. 23c. Receiving agency's bank routing number. 23d. Receiving agency's bank account number. IV-D agencies, courts, and attorneys (with authority to issue an income withholding order/notice) sending an Order/Notice to withhold Income for Child Support must complete 24a-e. 24a. Print name of the government official authorizing this Order or Notice to Withhold. 24b. Print title of the government official authorizing this Order or Notice to Withhold. 24c. Signature of Government Official authorizing this Order/Notice to Withhold and date of signature. This line may be optiona l only if the Withholding Order/Notice includes the name and title of a government official (line 24e, 24b) and a signature of the official ( line 24c) is not required by state or tribal law. Provide a signature if required by state or tribal law. 24d. Check the appropriate box to indicate whether a child support enforcement agency (IV-D) or court is authorizing this Order or Notice for withholding. 24e. Check the box if you are an attorney with authori ty to issue an order or notice under state law. Attorneys, individuals, and private entities sending a Notice of an Order to Withhold Income for Child Support complete 25a-d. 25a. Print name of the individual or entity sending this Notice. 25b. Print title of the individual sending this Notice, if appropriate. 25c. Signature of the individual sending this Notice and date of signature. 25d. Please check the appropriate box to indicate whether you are an attorney, individual, or private entity sending this Notice of an Order. The following information refers to federal, state, or tribal laws that apply to issuing an income withholding order/notice to the employer. Any state or tribal specific information may be included in space provided. 26. Check the box if the state or tribal law requires the employer to provide a copy of the Order or Notice to the employee. 27. Use this space to provide additional information on the penalty and/or citation for an employer who fails to comply with th e Order or Notice. The law of the obligor’s principal place of employment governs the facility. 28. Use this space to provide additional information on the penalty and/or citation for an employer, who discharges, refuses to employ, or disciplines an employee/obligor as a result of the Order or Notice. The law of the obligor’s principal place of employment gove rns the penalty. 29. Use this space to provide the child(ren)’s names listed in the support order and/or additional information regarding this income withhold Order or Notice of an Order. Please provide the following contact information to the employer. Employers may need additional information to process the Orde r or Notice . 30a. Name of the contact person sending the Order or Notice of an Order that an employers and/or employee/obligor may call for information regarding the Order or Notice of an Order. 30b. Telephone number for the contact person whose name appears in #30a. 30c. Fax number for the person whose name appears in #30a. 30d. Internet address for the person whose name appears in #30a. If the employer is a Federal Government Agency, the following instructions apply. ■ Serve the Order of Notice of an Order upon the governmental agent listed in 5 CFR part 581, appendix A. ■ Sufficient identifying information must be provided in order fo r the obligor to be identified. It is, therefore, recommended that the following information, if known and applicable, be provided: ■ (1) full name of the obligor; (2) date of birth; (3) employment number, Department of Veterans Affairs claim number, or civil s ervice retirement claim number; (4) component of the government entity for which the obligor works, and the official duty station or worksite; and (5) status of the obligor, e.g., employee, former employee, or annuitant. ■ You may withhold from a variety of incomes and forms of payment, including voluntary separation incentive payments (buy-out payments), incentive pay, and cash awards. For a more complete list see 5 CFR 581.103. The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 45 CFR 303.100 of the child support enforcement program. Standard f orms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of informati on is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be f iled with the tribunal and/or agency in the responding State an d may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection o f information unless it displays a currently valid OMB control number.