Notice of Order to Withhold Income for Child Support

ORDER / NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

OMB NO. 0970-0154

Original Amended Terminated Date:

State/Tribe/Territory

Co./City/Dist./Reservation

Non-governmental entity or individual

Case Number

Employer's/Withholder's Name

RE:

Employer's/Withholder's Address

Employee's/Obligor's Name (last, first, middle initial)

Employee's/Obligor's Social Security Number

Employee's/Obligor's Case Identifier

Obligee's Name (last, first, middle initial)

ORDER INFORMATION: This document is based on the support or withholding order from .

You are required by law to deduct these amounts from the employee's/obligor's income until further notice.

$ Per current child support

$ Per past-due child support - Arrears greater than 12 weeks? yes no

$ Per current cash medical support

$ Per past-due cash medical support

$ Per spousal support

$ Per past-due spousal support

$ Per other (specify)

for a total of $ per to be awarded to the payee below.

You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts.

$ per weekly pay period.

$ per biweekly pay period (every two weeks).

$ per semimonthly pay period (twice a month).

$ per monthly pay period.

REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier.

If the employee's/obligor's principal place of employment is , begin withholding no later than the first pay period occurring days after the date of . Send payment within working days of the pay date/date of withholding.

The total withheld amount, including your fee, cannot exceed % of the employee's/obligor's aggregate disposable weekly earnings.

If the employee's/obligor's principal place of employment is not , for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS).

Make check payable to:    Send check to:

If remitting payment by EFT/EDI, call before first submission.

Use this FIPS code:

Bank routing code:

Bank account number:

IV-D Agency Court Attorney Individual Private Entity

Attorney with authority under state law to issue order/notice.

NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state's law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the state law authorizing the attorney to issue an income withholding order/notice.

IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.

If you or your employee/obligor have any questions, contact:

by telephone at:

or by FAX at:

or by Internet at:

THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR:

EMPLOYEE'S/OBLIGOR'S NAME:

CASE IDENTIFIER:

DATE OF SEPARATION FROM EMPLOYMENT:

LAST KNOWN HOME ADDRESS:

NEW EMPLOYER ADDRESS:

If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this Order, a copy must be provided to your employee even if the box is not checked.

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

1. Priority: Withholding under this Order or Notice has priority over any other legal process under state law (or tribal law, if applicable) against the same income. If there are federal tax levies in effect, please notify the contact person below. (See 10 below.)

2. Combining Payments: You can combine withheld amounts from more than one employee's/obligor's income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

3. Reporting the Pay Date/Date of Withholding: You must report the pay date/date of withholding when sending the payment. The pay date/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments.

4. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order or Notice against this employee/obligor and you are unable to honor all support Orders or Notices due to federal, state or tribal withholding limits, you must follow the state or tribal law/procedure of the employee's/obligor's principal place of employment. You must honor all Orders or Notices to the greatest extent possible. (See 9 below.)

5. Termination Notification: You must promptly notify the Child Support Enforcement (IV-D) Agency and/or the contact person listed below when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this Order or Notice to the Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See 10 below.)

6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the Child Support Enforcement Agency.

7. Liability: If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below under 10. If you fail to withhold income as the Order or Notice directs, you are liable for both the accumulated amount you should have withheld from the employee's/obligor's income and any other penalties set by state or tribal law/procedure.

8. 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 any employee/obligor because of a child support withholding.

9. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. §1673(b); or 2) the amounts allowed by the state of the employee's/obligor's principal place of employment. The federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions, and Medicare taxes. The Federal CCPA limit if 50% of the ADWE for child support and alimony, which is increased by 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears greater than 12 weeks. 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.

Children's Names and Additional Information:

10. If you or your employee/obligor have any questions, contact:

by telephone at:

or by FAX at:

or by Internet at: