Fill and Sign the This Form is the Standard Format Prescribed by the Secretary in Accordance with Section 466b6aii of

INCOME WITHHOLDING FOR SUPPORT – InstructionsOMB 0970-0154 Expiration Date: 08/31/2020 INCOME WITHHOLDING FOR SUPPORT - Instructions The Income Withholding for Support (IWO) is the OMB-approved form used\ for income withholding in: tribal, intrastate, and interstate cases enforced under Title IV-D of th\ e Social Security Act all child support orders initially issued in the state on or after Janua\ ry 1, 1994, and all child support orders initially issued (or modified) in the state b\ efore January 1, 1994 if arrearages occur. This form is the standard format prescribed by the Secretary in accordan\ ce with section 466(b)(6)(a)(ii) of the Social Security Act. Except as noted, the following information is required and must be included. Please note: For the purpose of this IWO form and these instructions, “state” i\ s defined as a state or territory. Dos and don’ts on using this form are found at www.acf.hhs.gov/css/resource/using-the-income- withholding-for-support-form-dos-and-donts . COMPLETED BY SENDER: 1a. Income Withholding Order/Notice for Support (IWO) . Check the box if this is an initial IWO. 1b. Amended IWO . Check the box to indicate that this form amends a previous IWO. Any ch\ anges to an IWO must be done through an amended IWO. 1c. One-Time Order/Notice For Lump Sum Payment. Check the box when this IWO is to attach a one-time collection of a lump sum payment after receiving notification f\ rom an employer/income withholder or other source. When this box is checked, enter the amount \ in field 14, Lump Sum Payment, in the Amounts to Withhold section. Additional IWOs must be issued to collect subsequent lump sum payments. 1d. Termination of IWO. Check the box to stop income withholding on a child support order. Complete all applicable identifying information to aid the employer/inco\ me withholder in terminating the correct IWO. 1e. Date. Date this form is completed and/or signed. 1f. Child Support Enforcement (CSE) Agency, Court, Attorney, Private Indiv\ idual/Entity (Check One). Check the appropriate box to indicate which entity is sending the IWO.\ If this IWO is not completed by a state or tribal CSE agency, the sender should contact th\ e CSE agency (see www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-\ and-program- requirements ) to determine if the CSE agency needs a copy of this form to facilitat\ e payment processing. NOTE TO EMPLOYER/INCOME WITHHOLDER: This IWO must be regular on its face. The IWO must be rejected and retu\ rned to sender under the following circumstances: IWO instructs the employer/income withholder to send a payment to an ent\ ity other than a state disbursement unit (for example, payable to the custodial party, court, \ or attorney). Each state is required to operate a state disbursement unit (SDU), which is a centra\ lized facility for collection and disbursement of child support payments. Exception: If this IWO is i\ ssued by a court, attorney, or private individual/entity and the initial child support ord\ er was entered before January 1, 1994 or the order was issued by a tribal CSE agency, the employer/inc\ ome withholder must follow the payment instructions on the form. Form does not contain all information necessary for the employer to comp\ ly with the withholding. Form is altered or contains invalid information. FL-196 Page 1 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions Amount to withhold is not a dollar amount. Sender has not used the OMB-approved form for the IWO. A copy of the underlying order is required and not included. If you receive this document from an attorney or private individual/enti\ ty, a copy of the underlying support order containing a provision authorizing income withholding must be atta\ ched. COMPLETED BY SENDER: 1g. State/Tribe/Territory. Name of state or tribe sending this form. This must be a governmental entity of the state or a tribal organization authorized by a tribal gove\ rnment to operate a CSE program. If you are a tribe submitting this form on behalf of another tr\ ibe, complete field 1i. 1h. Remittance ID (include w/payment). Identifier that employers/income withholders must include when sending payments for this IWO. The Remittance ID is entered as the \ case identifier on the electronic funds transfer/electronic data interchange (EFT/EDI) record\ . NOTE TO EMPLOYER/INCOME WITHHOLDER: The employer/income withholder must use the Remittance ID when remitting\ payments so the SDU or tribe can identify and apply the payment correctly. The Remittance ID is\ entered as the case identifier on the EFT/EDI record. COMPLETED BY SENDER: 1i. City/County/Dist./Tribe. Optional field for the name of the city, county, or district sending this form. If entered, this must be a government entity of the state or the n\ ame of the tribe authorized by a tribal government to operate a CSE program for which this form is b\ eing sent. If a tribe is submitting this form on behalf of another tribe, enter the name of that \ tribe. 1j. Order ID. Unique identifier associated with a specific child support obligation. \ It could be a court case number, docket number, or other identifier designated by the sender\ . 1k. Private Individual/Entity. Name of the private individual/entity or non-IV-D tribal CSE organization sending this form. 1l . Case ID. Unique identifier assigned to a state or tribal CSE case. In a state IV\ -D case as defined at 45 Code of Federal Regulations (CFR) 305.1, this is the identifier \ reported to the Federal Case Registry (FCR). One IWO must be issued for each IV-D case and must use\ the unique CSE Agency Case ID. For tribes, this would be either the FCR identifier or o\ ther applicable identifier. Fields 2 and 3 refer to the employee/obligor’s employer/income withho\ lder and specific case information. 2a. Employer/Income Withholder's Name. Name of employer or income withholder. 2b. Employer/Income Withholder's Address. Employer/income withholder's mailing address including street/PO box, city, state, and zip code. (This may differ fr\ om the employee/obligor’s work site.) If the employer/income withholder is a federal government a\ gency, the IWO should be sent to the address listed under Federal Agency Income Withholding Conta\ cts and Program Information at www.acf.hhs.gov/css/resource/federal-agency-iwo-and-medical-contact- information . 2c. Employer/Income Withholder's FEIN. Employer/income withholder's nine-digit Federal Employer Identification Number (if available). FL-196 Page 2 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions 3a.Employee/Obligor’s Name. Employee/obligor’s last name and first name. A middle name is optional. 3b . Employee/Obligor’s Social Security Number. Employee/obligor’s Social Security number or other taxpayer identification number. 3c. Employee/Obligor’s Date of Birth. Employee/obligor’s date of birth is optional. 3d. Custodial Party/Obligee’s Name. Custodial party/obligee’s last name and first name. A middle name is optional. Enter one custodial party/obligee’s name on each IWO form. Multiple\ custodial parties/obligees are not to be entered on a single IWO. Issue one IWO pe\ r state IV-D case as defined at 45 CFR 305.1. 3e. Child(ren)’s Name(s). Child(ren)’s last name(s) and first name(s). A middle name(s)\ is optional. (Note: If there are more than six children for this IWO, list additiona\ l children’s names and birth dates in the Supplemental Information section). Enter the child(ren) associated with the custodial party/obligee and employee/obligor only. Child(ren) of multi\ ple custodial parties/obligees is not to be entered on an IWO. 3f. Child(ren)’s Birth Date(s). Date of birth for each child named. 3g. Blank box. Space for court stamps, bar codes, or other information. ORDER INFORMATION – Field 4 identifies which state or tribe issued the order. Fields 5 \ through 12 identify the dollar amounts for specific kinds of support (taken direct\ ly from the support order) and the total amount to withhold for specific time periods. 4. State/Tribe. Name of the state or tribe that issued the support order. 5a-b. Current Child Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 6a-b. Past-due Child Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 6c. Arrears Greater Than 12 Weeks? The appropriate box (Yes/No) must be checked indicating whether arrears are greater than 12 weeks. 7a-b. Current Cash Medical Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 8a-b. Past-due Cash Medical Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 9a-b. Current Spousal Support. (Alimony) Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 10a-b. Past-due Spousal Support. (Alimony) Dollar amount to be withheld p er the time period (for example, week, month) specified in the underlying order. 11a-c. Other. Miscellaneous obligations dollar amount to be withheld per the time period (for example, week, month) specified in the underlying order. Must specify a description of the obligation (for example, court fees). 12a-b. Total Amount to Withhold. The total amount of the deductions per the corresponding time period. Fields 5a, 6a, 7a, 8a, 9a, 10a, and 11a should total the amount \ in 12a. FL-196 Page 3 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions NOTE TO EMPLOYER/INCOME WITHHOLDER: An acceptable method of determining the amount to be paid on a weekly or\ biweekly basis is to multiply the monthly amount due by 12 and divide that result by the number of pay\ periods in a year. Additional information about this topic is available in Action Transmittal 16-04, Correctly Withholding Child Support from Weekly and Biweekly Pay Cycles ( https://www.acf.hhs.gov/css/resource/correctly-withholding-child- support-from-weekly-and-biweekly-pay-cycles ). COMPLETED BY SENDER: AMOUNTS TO WITHHOLD - Fields 13a through 13d specify the dollar amount to be withheld for t\ his IWO if the employer/income withholder’s pay cycle does not correspond\ with field 12b. 13a. Per Weekly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid weekly. 13b. Per Semimonthly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid twice a month. 13c. Per Biweekly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid every two weeks. 13d. Per Monthly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid once a month. 14. Lump Sum Payment. Dollar amount withheld when the IWO is used to attach a lump sum payment. This field should be used when field 1c is checked. 15. Document Tracking ID. Optional unique identifier for this form assigned by the sender. Please Note: Employer’s Name, FEIN, Employee/Obligor’s Name and SSN, Case ID, a\ nd Order ID must appear in the header on page two and subsequent pages. REMITTANCE INFORMATION - Payments are forwarded to the SDU in each state, unless the initial ch\ ild support order was entered by a state before January 1, 1994 and never mo\ dified, accrued arrears, or was enforced by a child support agency or by a tribal CSE agency. If the ord\ er was issued by a tribal CSE agency, the employer/income withholder must follow the remittance instru\ ctions on the form. 16. State/Tribe. Name of the state or tribe sending this document. 17. Days. Number of days after the effective date noted in field 18 in which with\ holding must begin according to the state or tribal laws/procedures for the employee/obligo\ r’s principal place of employment. 18. Date. Effective date of this IWO. 19. Business Days. Number of business days within which an employer/income withholder must\ remit amounts withheld pursuant to the state or tribal laws/procedures o\ f the principal place of employment. 20. Percentage of Disposable Income. The percentage of disposable income that may be withheld from the employee/obligor’s paycheck. It is the sender’s responsib\ ility to determine the percentage an employer/income withholder is required to withhold. FL-196 Page 4 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions NOTE TO EMPLOYER/INCOME WITHHOLDER: The employer/income withholder may not withhold more than the lesser of:\ the amounts allowed by the Federal Consumer Credit Protection Act [15 USC §1673(b)]; or 2) th\ e amounts allowed by the jurisdiction of the employee/obligor’s principal place of employment (i.e., the a\ mounts allowed by state law if the employee/obligor’s principal place of employment is in a state; or th\ e amounts allowed by tribal law if the employee/obligor’s principal place of employment is under tribal juri\ sdiction). State-specific withholding limitations, time requirements, and any allowable employer fees are avai\ lable at http://www.acf.hhs.gov/ css/resource/state-income-withholding-contacts-and-program-requirements . For tribe- specific contacts, payment addresses, and withholding limitations, please contact the tribe\ at www.acf.hhs.gov/sites/ default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf or https://www.bia.gov/tribalmap/ DataDotGovSamples/tld_map.html . A federal government agency may withhold from a variety of incomes and f\ orms 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. COMPLETED BY SENDER: 21. State/Tribe. Name of the state or tribe sending this document. 22. Locator Code. Geographic Locator Codes are standard codes for states, counties, and c\ ities issued by the National Institute of Standards and Technology. These were\ formerly known as Federal Information Processing Standards (FIPS) codes. 23. SDU/Tribal Order Payee. Name of SDU (or payee specified in the underlying tribal support order) to which payments must be sent. 24. SDU/Tribal Payee Address. Address of the SDU (or payee specified in the underlying tribal support order) to which payments must be sent. COMPLETED BY EMPLOYER/INCOME WITHHOLDER: 25. Return to Sender Checkbox. The employer/income withholder should check this box and return the IWO to the sender if this IWO is not payable to an SDU or Tribal Pay\ ee or this IWO is not regular on its face as indicated on page 1 of these instructions. COMPLETED BY SENDER IF REQUIRED BY STATE OR TRIBAL LAW: 26. Signature of Judge/Issuing Official. Signature of the official authorizing this IWO. 27. Print Name of Judge/Issuing Official. Name of the official authorizing this IWO. 28. Title of Judge/Issuing Official. Title of the official authorizing this IWO. 29. Date of Signature. Date the judge/issuing official signs this IWO. 30. Copy of IWO checkbox. Check this box for all intergovernmental IWOs. If checked, the employer/income withholder is required to provide a copy of the IWO to t\ he employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS The following fields refer to federal, state, or tribal laws that apply \ to issuing an IWO to an employer/ income withholder. State- or tribal-specific information may be included\ only in the fields below. FL-196 Page 5 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions COMPLETED BY SENDER: 31. Liability. Additional information on the penalty and/or citation of the penalty fo\ r an employer/income withholder who fails to comply with the IWO. The state o\ r tribal law/procedures of the employee/obligor’s principal place of employment govern the pe\ nalty. 32. Anti-discrimination. Additional information on the penalty and/or citation of the penalty fo\ r an employer/income withholder who discharges, refuses to employ, or discipl\ ines an employee/ obligor as a result of the IWO. The state or tribal law/procedures of th\ e employee/obligor’s principal place of employment govern the penalty. 33. Supplemental Information. Any state-specific information needed, such as maximum withholding percentage for nonemployees/independent contractors, fees th\ e employer/income withholder may charge the obligor for income withholding, or children’\ s names and DOBs if there are more than six children on this IWO. Additional information must be c\ onsistent with the requirements of the form and the instructions. COMPLETED BY EMPLOYER/INCOME WITHHOLDER: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS The employer must complete this section when the employee/obligor’s e\ mployment is terminated, income withholding ceases, or if the employee/obligor has never worked for the \ employer. 34a-b. Employment/Income Status Checkbox. Check the employment/income status of the employee/ obligor. 35. Termination Date. If applicable, date employee/obligor was terminated. 36. Last Known Telephone Number. Last known (home/cell/other) telephone number of the employee/obligor. 37. Last Known Address. Last known home/mailing address of the employee/obligor. 38. Final Payment Date. Date employer sent final payment to SDU/Tribal Payee. 39. Final Payment Amount. Amount of final payment sent to SDU/Tribal Payee. 40. New Employer’s Name. Name of employee’s/obligor’s new employer (if known). 41. New Employer’s Address. Address of employee’s/obligor’s new employer (if known). COMPLETED BY SENDER: CONTACT INFORMATION 42. Issuer Name (Employer/Income Withholder Contact). Name of the contact person that the employer/income withholder can call for information regarding this IWO. 43. Issuer Telephone Number. Telephone number of the contact person. 44. Issuer Fax Number. Optional fax number of the contact person. 45. Issuer Email/Website. Optional email or website of the contact person. 46. Issuer Address (Termination/Income Status and Correspondence Address).\ Address to FL-196 Page 6 of 7 INCOME WITHHOLDING FOR SUPPORT – Instructions which the employer should return the Employment Termination or Income St\ atus notice. It is also the address that the employer should use to correspond with the issuing \ entity. 47. Issuer Name (Employee/Obligor Contact). Name of the contact person that the employee/ obligor can call for information. 48. Issuer Telephone Number. Telephone number of the contact person. 49. Issuer Fax Number. Optional fax number of the contact person. 50. Issuer Email/Website. Optional email or website of the contact person. Encryption Requirements: When communicating the Income Withholding for Support (IWO) through el\ ectronic transmission, precautions must be taken to ensure the security of the data. Child supp\ ort agencies are encouraged to use the electronic applications provided by the federal Office of Child\ Support Enforcement. Other electronic means, such as encrypted attachments to emails, may be used i\ f the encryption method is compliant with Federal Information Processing Standard (FIPS) Publicat\ ion 140-2 (FIPS PUB 140-2). The Paperwork Reduction Act of 1995 This information collection and associated responses are conducted in ac\ cordance with 45 CFR 303.100 of the Child Support Enforcement Program. This form is designed to prov\ ide uniformity and standardization. Public reporting burden for this collection of informa\ tion is estimated to average 5 minutes per response for Non-IV-D CPs; 2 minutes per response for employ\ ers; 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 re\ spond to, a collection of information unless it displays a currently valid OMB control number. FL-196 Page 7 of 7