CONFIDENTIAL PER HCRR RULE 9 NAME: ADDRESS: TELEPHONE NO.: [ ] Attorney for Plaintiff/Petitioner [ ] Plaintiff/Petitioner Pro Se [ ] Attorney for Defendant/Respondent [ ] Defendant/Respondent Pro Se IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I [ ] Child Support Enforcement Agency (CSEA), ) ) State of Hawai`i, and ) ,) [ ] Mother [ ] Father [ ] Other ) Petitioner(s)/Plaintiff(s), ) ) v. ) ) ,) ) [ ] Mother [ ] Father [ ] Other ) ,) [ ] Mother [ ] Father [ ] Other ) ) ) [ ] and Child Support Enforcement Agency ) State of Hawai`i, Respondent(s)/Defendant(s). ) ) FC-P No. [ ] ORIGINAL [ ] AMENDED [ ] ONE-TIME/LUMP SUM PAYMENT [ ] TERMINATION ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT [ ] ORIGINAL [ ] AMENDED [ ] ONE-TIME/LUMP SUM [ ] TERMINATION ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. Reprographics (10/2015) 1F-P-888 American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified INCOME WITHHOLDING FOR SUPPORT (Check One) [ [ [ [ ] ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) ] AMENDED INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT ] ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT ] TERMINATION OF INCOME WITHHOLDING ORDER Date: Child Support Enforcement Agency (CSEA) Court Attorney Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions: http://www.acf.hhs.gov/programs/css/resource/income-withholding-for support-instructions). If you receive this document from someone other than a State or Tribal CSEA or a Court, a copy of the underlying order must be attached. State/Tribe/Territory: City/County/Dist./Tribe: Private Individual/ Entity: Remittance Identifier (include w/ payment): Order Identifier: CSEA Case Identifier: RE: Employer/Income Withholder's Name Employer/Income Withholder's Address Employee/Obligor's Name (Last, First, Middle) Employee/Obligor's Social Security Number Custodial Party/Obligee's Name (Last, First, Middle) Employer/Income Withholder's FEIN: Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) (State/Tribe). ORDER INFORMATION: This document is based on the support or withholder order from You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ $ $ $ $ $ $ Per Per Per Per Per Per Per current child support past-due child support - Arrears greater than 12 weeks? Yes current cash medical support past-due cash medical support current spousal support past-due spousal support other (must specify) per . ORDER/NOTICE TO WITHHOLD INCOME 1F-P-888 American LegalNet, Inc. www.FormsWorkFlow.com No . for a Total Amount to Withhold of $ FC Adm 9/29/15 Page 2 of 6 Employer's Name: Employee/Obligor's Name: CSEA Case Identifier: Employer FEIN: SSN: Order Identifier: AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ $ $ per weekly pay period $ per semimonthly pay period (twice a month) per monthly pay period per biweekly pay period (every 2 weeks) $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is in Hawai`i, you must begin withholding no later than the first pay period that occurs 7 days after the date of mailing to you. Send payment within 5 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to (see Withholding Limits, below) of disposable income. If the obligor is a non-employee, obtain withholding limits from Supplemental Information below. If the employee/ obligor's principal place of employment is not in Hawai`i, obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/css/resources/state-income-withholding-contacts and-program-information for the employee/obligor's principal place of employment. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit [SDU]), see http://www.acf.hhs.gov/programs/css/employers/ electronic-payments. Include the Remittance Identifier with the payment and if necessary this FIPS code: Remit payment to the CHILD SUPPORT ENFORCEMENT AGENCY at: CHILD SUPPORT ENFORCEMENT AGENCY STATE DISBURSEMENT BRANCH P.O. BOX 1860 HONOLULU, HI 96805-1860 [Completed by Employer/Income Withholder]. Payment must be directed to a SDU in accordance with 42 USC § 666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to a SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. . Return to Sender Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. FC Adm 9/29/15 Page 3 of 6 ORDER/NOTICE TO WITHHOLD INCOME 1F-P-888 American LegalNet, Inc. www.FormsWorkFlow.com Employer's Name: Employee/Obligor's Name: CSEA Case Identifier: Employer FEIN: SSN: Order Identifier: ADDITIONAL INFORMATION FOR EMPLOYER/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at: www.acf.hhs.gov/programs/css/resources/state-income-withholding-contacts-and-program-information. Priority: Withholding for support has priority over any other legal process under State law against the same income (42 USC §666(b)(7)). If a Federal tax le