Fill and Sign the To Employerswithholders Nameaddress Form

CSMOD 20 . Notice to Payor Revised July 200 7 Page 1 of 6 STATE OF WYOMING ) IN THE DISTRICT COURT ) ss . COUNTY OF __________________) _______________ JUDICIAL DISTRICT ________________________________ ) ) Plaintiff , ) ) vs. ) Civil Action No. ____________________ ) _________ ______________________ ) ) Defendant . ) NOTICE TO PAYOR Original  Amended Termination TO: [Employer’s /Withholder’s Name/Address] ___________________________________ ___________________________________ ___________________________________ 1. You shall remit all sums withheld from the obligor’s income to t he clerk of district court or the State Disbursement Unit as set forth in paragraph 3 of this Notice to Payor . By law, you are required to deduct these amounts from the above -named employee’s/obligor’s income, until further notice, ev en if the Order/Notice is not issued by your State. 2. Withholding Amount : The total amount to be withheld from the obligor’s income is calculated as follows: $ Per Current child support $ Per Past due child support Arrears greater than 12 week s?  yes  no $ Per Current cash medical support $ Per Past -due cash medical support $ Per Spous al support $ Per Past -due spousal support $ Per Other (specif y) Total Amount Due Upon rec eipt of certified copies of the notice to payor and the income withholding order, the payor shall deduct and pay over a total of $ per month weekly bi-weekly semi -monthly is to be with held f rom the obligor’s income starting the ______ __ day of ___________________ __, 20___ ___, and continuing until further order of the Court. CSMOD 20 . Notice to Payor Revised July 200 7 Page 2 of 6 3. REMITTANCE INFORMATION: When remitting payment, provide the case identifier , the name and social security n umber of the obligor and the date the income was withheld. If the employee’s/obligor’s principal place of employment is Wyoming, you must begin withholding no later than the first pay period that occurs following service on the payor of this Order/Notice. Send payment within 7 working days of the pay date/date of withholding . You do not have to vary your pay cycle to be in compliance with the support order. A. The payor shall remit the amount withheld to the clerk of d istrict court , whose address is: within seven (7) days after the date the obligor is paid, or (if checked) the State Disbursement Unit, Wyoming Child Support Enforcement , PO Box 1027 , Cheyenne, WY 82003 . If the employee’s/obligor’s princi pal place of employment is not Wyoming, 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. 4. Priority : The withholdin g under this order has priority over any other legal process under state law (or tribal law, if applicable) against the same income. Federal tax levies in effect before receipt of this order have priority. If Federal tax levies are in effect, p lease cont act the State Child Support Enforcement Agency. 5. Combined Payments : You may 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 identi fy the portion of the single payment that is attributable to each employee/obligor. 6. 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 the employee’s/obligor’s principal place of employment with respect to the time periods within which you must implement the withholding and forward the su pport payments. 7. 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 Withholding Limits below.) CSMOD 20 . Notice to Payor Revised July 200 7 Page 3 of 6 8. Termination Notification: Within thirty (30) days after the employee ’s/obligor ’s employment terminates or the employee/ obligor ceases to receive income from the payor the payor shall give written notice to the clerk of district court. The notice shall include the following information: TH E 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: 9. Continuing Duty : For a period of on e (1) year from the date the employee’s/ obligor’s employment terminates with the payor, the payor shall, upon request, disclose to the Clerk of this Court, the following information: A. Any new address for the obligor of which the payor may become aware; and B. The name and address of the obligor’s new employer, if known to the payor. 10. Worker’s Compensation and Unemployment : In the case of worker’s compensation or unemployment compensation benefits, nothing in W. S. 20 -6-202(a)(i) or (xv) shall requi re a payor to withhold an amount for any type of support or arrearages not authorized to be withheld from those benefits by federal law or regulations. 11. Change in Insurance Coverage : If insurance coverage of the obligor’s children is provided by or through the payor, the payor shall notify the clerk within thirty (30) days of any lapse or material change in that coverage. 12. The payor shall not be liable to the obligor for any payment or disclosure made as authorized by this act. 13. Lump Sum P ayments: 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 (IV -D) Agency. 14. Withholding Limits: The amount actually withheld for support combined with the fee authorized by W.S. 20 -6-212(c) ( five dollars ($5.00) for each payment made pursuant to the income withholding order) shall not exceed the maximum amount authorized by 15 U.S.C. §1673. * For state o rders, 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 l imit 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 CSMOD 20 . Notice to Payor Revised July 200 7 Page 4 of 6 pension contributions, and Medicare taxes. The payor shal l deduct the maximum amount required by this notice, unless otherwise ordered by the court, for each pay period. * The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by 1) 10% if the employee does not support a se cond 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. CHILD (REN )’S NAME (S): DATE OF BIRTH : 1. __________________________ ______________________ 2. __________________________ ______________________ 3. __________________________ ________________ ______ 15. Statutory Fee : As authorized by Wyo. Stat. § 20 -6-212(c), i n addition to the amount withheld from the obligor’s income, the payor may, subject to limitations of disposable income under W. S. § § 20 -6-210 (b)(iii) and 27 -3-319 (c), deduct and retain from the obligor’s remaining income $5.00 for each payment made pursuant to the Income Withholding Order . 16. Sanctions: The payor is notified that payor is subject to the sanctions of W yo . Stat . § 20 -6-218, including the following: A. Liability : Any payor who fails to withhold income in the amount specified in the Notice to Payor is liable for any amount up to the accumulated amount the payor should have withheld from the obligor’s income and remitted to th e clerk of this court. B. Anti -discrimination : You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child sup port withholding. The penalt ies imposed under W yo . Stat . § 20 -6-218 shall be collected from the violator and distributed by the court to the county public school fund. Before the court imposes a civil penalty, the payor accused of a violation shall be not ified, in writing, of the specific nature of the alleged violation and the time and place, at least ten (10) days from the date of the notice, when a hearing of the matter shall be held. After hearing or upon failure of the accused to appear at the hearin g, the court shall determine the amount of the civil penalty to be imposed in accordance with t he limitation in W yo . Stat . § 20 -6-218 . C. Any payor who violates the provisions set forth in Wyo. Stat. § 20 -6-202 et seq. is subject to a civil penalty in a n amount of not more than two hundred dollars ($200.00). D. Penalties under Wyoming statutes shall not be imposed unless service of the notice to payor was completed by sending by certified mail return receipt requested to, or by persona l service upon, the employer. CSMOD 20 . Notice to Payor Revised July 200 7 Page 5 of 6 E. Except for a violation of subsection ( B) of this section, an employer who complies in good faith with an income withholding order shall not be subject to civil liabilities. F. If you have any doubts about the validity of the Order or Notice, contact the Child Support Enforcement Agency or Clerk of District Court . 17. Duration : The Income Withholding Order is binding upon the payor until further notice is received as provided in accordance with W.S. 20 -6-210(a). 18. This Notice to Payor shall be prepared and filed with the Clerk before an Income Withholding Order is mailed to the payor . DATED this ______ day of _________________, 20___. CLERK OF DISTRICT COURT By:________________________________ Deputy CERTIFICATE OF MAILING The undersigned c ertifies that a copy of the Notice to Payor and a copy of the Income Withholding Order were mailed the ______ day of ______________ __, 20_____, by First - class U.S. mail, postage prepaid, or certified mail return receipt requested to the last known address of the payor (employer of the parent obligated to pay child support) and the obligor (parent owing support) as follows: Employer/ Payor’s Address: _____________________________ _____________________________ _____________________________ _____________________________ Employee/ Obligor’s Address: _____________________________ _____________________________ _____________________________ _____________________________ ____________________________________ Signature (of person filing out this form) Name: (Please print) ________________________ CSMOD 20 . Notice to Payor Revised July 200 7 Page 6 of 6