IN THE DISTRICT COURT OF DOUGLAS COUNTY, NEBRASKA ______________________________________________ Petitioner/Plaintiff, vs. ______________________________________________ Respondent/Defendant. ) ) ) ) ) ) ) CASE NO. __________________________ NOTICE TO WITHHOLD INCOME (Voluntary) Date: TO: _________________________________________ Employer/Other Obligor Employer Address RE: Employee (Obligor) ___________________________________ (Employee/Obligor Address) Employee Soc. Sec. No.: ___________________________________ Employer Telephone Number PURSUANT TO NEBRASKA REVISED STATUTE, SEC, 43-1718.02, YOU ARE HEREBY NOTIFIED OF THE FOLLOWING: (1) The above-named employee is ordered to have an amount withheld from his/her income to satisfy a child/spousal/medical support obligation. You are hereby directed to withhold $ __________________ per _________________ (or the equivalent based on your pay period-from the net disposable income of your employee, or ________________ % of the employee's net disposable income subject to CCPA limits (See (9)), whichever is less. For the purpose of income withholding, "net disposable income" is defined as that part of the employee's earnings remaining after the deductions for payment of federal and state income taxes, employment taxes, FICA deductions, mandatory retirement and federal or state income tax liens. (2) The above amount is based on the employee's ordered support obligation of-, Child/Day Care $ ______________________ per ________________ and arrears of $ ______________ as of __________ Spousal Support $ ______________ per ________________ and arrears of $ ______________ as of __________ (Spousal support only ­ no child support order entered) Court Order Medical (circle one) $ _____________________________ per _______________ (3) Income withholding must be implemented NO LATER THAN the first pay period occurring after fourteen (14) days following the date of this notice. If the withholding is for an employee and he/she takes an advance draw on his/her income, each draw is to be considered a pay period for the purpose of income withholding. You MUST forward the withheld amounts to the Clerk of the Douglas County District Court at the address listed below WITHIN TEN (10) DAYS of the date the employee is paid (whether on regular payday or earlier, whichever occurs first). SEND WITHHELD AMOUNTS TO: Clerk of the District Court - Douglas County Courthouse Hall of Justice - Room #300 Omaha, ,NE 68183 REMITTANCE MUST INCLUDE: EMPLOYEE'S NAME, Social Security Number, DOCKET AND PAGE NUMBER and the date on which the amount was withheld from the employee's wages or other income (i.e. the employee's payday). (6) The employee (has _____/has not _____ been ordered to provide health insurance coverage for his/her dependent children. You may retain an additional amount from the employee's net disposable income not to exceed $2.50 per month to offset the administrative costs associated with the Notice to Withhold Income. You shall pay the employee on his/her regularly scheduled payday the amount earned minus the support amount indicated on this Notice. The sum total of the amount to be withheld, including the administrative fee, is limited to the amount specified in the Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)). The limits provided in the CCPA are 50% of net (4) (5) (7) (8) disposable income in the case of an employee who has a second family and 60% if there is no second family. These limits are increased by 5 percentage points (to 55 or 65) if the delinquent amount is more than 12 weeks in arrears. (9) The amounts withheld pursuant to income withholding shall have priority over any other secured or unsecured claim of income, wage assignment, garnishment, execution or other attachment except for other support orders being withheld and federal, state or local taxes. If you are required to withhold income from more than one employee payable to the Douglas County Clerk of the District Court, you may combine the withheld amounts in a single payment and separately identify the portion of the single payment that is attributed to each employee's Social Security number, the respective support order number and the date on which the amount was withheld from the employee's wages or other income. If you receive more than one notice to withhold for a single employee and the income available to be withheld is insufficient to satisfy all notices based on the Consumer Credit Protection Act, the support amount should be calculated as follows-. (a) Withhold current support for each order. If the income available to be withheld is less than the total current support in the notices, withhold the proportion that the amount of current support in each notice bears to the total amount of current support in all notices. Example: You receive two notices to withhold income - one notice for $100 and one notice for $150, for a total of $250. If only $200 is available to be withheld, calculate as follows: $100/250 = 40%, 40% x $200 = $80, $150/250 = 60%, 60% x $200 = $120. Withhold $80 for the $100 notice and $120 for the $150 notice. (b) When the income available to be withheld is enough to cover all the current support, apply any remaining available income to arrearages. If the remaining income available for arrearages is less than the total arrearages in the notices, withhold the proportion that the amount of each arrearage bears to the total amount of arrearage (See Example in (a)). (10) (11) (c) (12) This income withholding requirement is binding and shall continue in full force and effect until 30 days after the employee ceases employment of the source of income terminates. The withholding shall also terminate when the obligor supplies proof that the child, spousal and medical support obligation terminates. The income withholding requirement may be modified or revoked by a court of competent jurisdiction. IF YOU FAIL TO WITHHOLD INCOME UNDER the PROVISIONS OF THIS NOTICE, YOU ARE LIABLE FOR THE ACCUMULATED AMOUNT WHICH SHOULD HAVE BEEN WITHHELD FROM THE EMPLOYEE'S INCOME. You shall refrain from dismissing, demoting, disciplining, discharging or refusing to employ or in any way penalizing the employee as a result of this Notice. The court may impose a civil fine of up to $500 for each violation. Upon termination of the employee's employment for any reason, return a copy of this Notice to the Clerk of the District Court within 30 days of such termination and provide th