Fill and Sign the Notice of an Order to Withhold Income for Child Support Form

Page 1 of 2 Individual 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. If remitting payment by EFT/EDI, call Use this FIPS code: Bank routing code: Bank account number: before first submission. If this is an Order/Notice to Withhold: If this is a Notice of an Order to Withhold: Print Name Title Of Issuing Official Signature and Date Print Name Title (if appropriate) Signature and Date IV-D Agency Court Attorney Private Entity Attorney with authority under state law to issue order/notice. Make check payable to: (Payee and Case Identifier) Send check to: 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 withholding no later than the first pay period occurring payment within cannot exceed current child support past-due child support - Arrears greater than 12 weeks? current cash medical support past-due cash medical support spousal support past-due spousal support other (specify) 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. ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT OMB NO. 0970-0154 Original Employee's/Obligor's Social Security Number Employee's/Obligor's Case Identifier Obligee's Name (last, first, middle initial) Amended State/Tribe/Territory Co./City/Dist./Reservation Date: Case Number Non-governmental entity or individual Employee's/Obligor's Name (last, first, middle initial) RE: Employer's/Withholder's Address Employer's/Withholder's Name Employer's/Withholder's Federal EIN Number (if known) , begin days after the date of . Send working days of the pay date/date of withholding. The total withheld amount, including your fee, % of the employee's/obligor's aggregate disposable weekly earnings. If the employee's/obligor's principal place of employment is not 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). , for limitations IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. Terminated . Per Per Per Per Per Per Per $ $ $ $ $ $ $ yes no 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. $ $ If you or your employee/obligor have any questions, contact: by telephone at: or by Internet at: THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: EMPLOYEE'S/OBLIGOR'S NAME: 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. Page 2 of 2 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.) 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. 9. 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. Children's Names and Additional Information: 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. 8. CASE IDENTIFIER: 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. 10. or by FAX at: