STATE OF HAWAI‘I FAMILY COURT _________ CIRCUIT CASE NUMBER ORDER FOR INCOME WITHHOLDING FC-D NO. Preparer’s Name, Address and Telephone Number PLAINTIFF, VS. DEFENDANT. Hearing Date: Judge: Date Support Order Filed: TO THE EMPLOYER OR SUCCESSOR EMPLOYER OF: Employee/Obligor: Address: Social Security Number: IT IS HEREBY ORDERED that: I. Pursuant to Hawai‘i Revised Statutes (HRS) §§ 571-52.2 and 52.3, the employer or successor employer shall: A. Withhold from any salary, wages or any entitlement of money payable to the above employee/obligor, the amount of $_____________ per month. The amount to be withheld may be apportioned from each pay period in the month. The withholding, including a $2.00 administrative fee charged to the employee/obligor, shall not exceed the maximum permitted by section 303(b) Consumer Credit Protection Act (15 USC 1673(b)); B. Begin withholding the above amount no later than the first pay period within seven (7) days after a certified copy of this order is mailed to the employer. C. Deliver the withheld amount payable to the Child Support Enforcement Agency (CSEA), P.O. Box 1860, Honolulu, Hawai‘i 96805-1860 no later than five (5) business days after the employee/obligor has been paid. If employer is ordered to withhold amounts for more than one employee/obligor, the total withholdings may be paid in one check with a list of amounts applicable to each employee/obligor by case number, name and social security number. II. The employer is notified that: A. It may charge the employee/obligor a $2.00 administrative fee for each payment made to CSEA. Said fee shall not be deducted from the amount paid the CSEA (HRS §571-52.2(f)); B. This withholding order has priority over any other garnishment, attachment, execution or assignment and is not subject to exemptions or restriction s under HRS Chapter 651, 652 and 653 (HRS §571-52.2(f)); C. It is unlawful for an employer to ignore this order. Failure to comply with this order will result in the employer being responsible for the full amount ordered to be withheld (HRS §571-52.2(g)); D. It is a crime for an employer to refuse to hire, discharge or discipline a (prospective) employee/obligor due in any part to this order. (HRS §§571-52(c), 710-1077(1)(g), 706-640, and 706-663. Penalties include imprisonment and fines. REVISED 2/99 ORDER FOR INCOME WITHHOLDING American LegalNet, Inc. www.FormsWorkflow.com