LDSS - 5038 ( 8/18 ) INCOME WITHHOLDING ORDER Court Information County Order ID (Index/Docket Number) Employee/Obligor Information Name ( Last , First , Middle) Social Security Number - - Date of Birth (MM/DD/YYYY) / / Obligee Information Name ( Last , First , Middle) Mailing Address Part A I mportant N otice If you are issuing a Spousal Support Only Income Withholding Order, yo u must serve the completed LDSS - 5038 as follows: Part A: serve only upon the employer/income withholder. Part B: serve upon all of the following: 1. employer/income withholder; 2. employee/obligor; and 3. obligee. American LegalNet, Inc. www.FormsWorkFlow.com Page intentionally left blank. American LegalNet, Inc. www.FormsWorkFlow.com Income Withholding for Support (IWO) OMB 0970 - 01 54 Expiration Date: 08/31/2020 Page 1 of 4 LDSS - 5038 ( 8 /1 8 ) INCOME WITHHOLDING FOR SUPPORT INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE - TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO Date: Child Support Enforcement (CSE) Agency 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 www.acf.hhs.gov/css/resource/income - withholding - for - support - instructions ). If you receive this docu ment from someone other than a state or tribal CSE agency or a c ourt, a copy of the underlying order must be attached. State/Tribe/Territory Remittance ID (include w/payment) City/County/Dis t./Tribe Order ID Private Individual/En tity Case ID RE: Employee/ Obligor Date of Birth Custodial Party/ ORDER INFORMATION : This document is based on the support order from New Yo rk State . You are required by law to $ Per current child support $ Per past - due child support Arrears greater than 12 weeks? Yes No $ Per current cash medical support $ Per past - due cash medical support $ Per current spousal support $ Per past - due spousal support $ Per other ( must specify) for a Total Amount to Withhold of $ per . 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 biweekly pay period (every two weeks) $ per monthly pay period $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. Document Tracking ID NOTE - Grayed out areas of this form are NOT applicable to spousal support only cases Part B American LegalNet, Inc. www.FormsWorkFlow.com Employer FEIN: SSN: Case Identifier : Order I dentifier : Income Withholding for Support (IWO) Page 2 of 4 REMITTANCE INFORMATION : withholding no later than the first pay period that occurs 14 days after the date of service of this notice. Send payment within 7 business days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold % of disposable income for all orders. If the obligor is a non - employee, obtain withholding limits from Supplemental Information . If the emplo withholding limitations, time requirements, and any allowable employer fees principal place of employment. State - specific withholding limit information is available at www.acf.hhs.gov/css/resource/state - income - withholding - contacts - and - program - requirements . For tribe - specific c ontacts, payment addresses, and withholding limitations, please contact the tribe at www.acf.hhs.gov/sites/default/files/programs/css/tribalagencycontactsprintablepdf.pdf or https://www.bia.gov/tribalmap/DataDotGovSamples/tldmap.html . For electronic payment requirements and centralized payment collection and disbursement facility information [State Disbursement Unit (SDU)], see www.acf.hhs.gov/css/employers/employer - respon sibilities/payments . Include the Remittance ID , pay date and Make payments payable in the name of the obligee identified on PART A . Remit payment to o PART A . Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with sections 466 (b)(5) and ( 6) of the Social Security Act or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tr ibal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. If Required by State or Tribal Law: Signature of Judge/Is suing Official : Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: If t he employee/obligor works in a state or for a t r ibe that is different from the state or t ribe 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. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State - specific contact and withholding information can be found on the Federal Employer Services website located at: www.acf.hhs.gov/css/resource/state - income - withholding - contacts - and - program - requirements https://ocsp.acf.hhs.gov/csp/ ) to provide information about employees who are eligible to receive a lump sum payment, have terminated employment, and to provide contacts, addresses, and other information about their company. Priority: Withholding for support has priority over any other legal process under S tate law against the same income (section 4 66(b)( 7) of the Social Security Act . If a f ederal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or t ribal CSE agency, you may combine withheld amounts Payments To SDU: You must send child support payments payable by income withholding to the appropria te SDU or to a t ribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU ( e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: I f this IWO was sent by a c ourt, a ttorney, or p rivate i ndividual/ e ntity and the initial order was entered before January 1, 199 4 or the order was issued by a t American LegalNet, Inc. www.FormsWorkFlow.com Employer FEIN: SSN: Case Identifier : Order I dentifier : Income Withholding for Support (IWO) Page 3 of 4 Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the ust comply with the law of the s tate ( or t ribal law if applicable) of the em the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to federal, state, or t ribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past - due support. Follow the s tate or t ribal law/procedure of the employ principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IW O, contact the sender. If you fail to withhold income from the and any penalties set by state or t ribal law/procedure , together with inte If you comply with this IWO you will not be subject to civil liability to any individual or agency for conduct in compliance with this IWO. In New York State, pursuant to Civil Practice Law and Rules (CPLR) 2475241, upon a finding by the Family Court that you failed to withhold or remit withholdings as directed in this IWO, the Court shall issue an order directing your compliance and may direct the payment of a civil penalty not to exceed $500 for the first instance a nd $1,000 per instance for the second and subsequent instances of noncompliance. Anti - discrimination: You are subject to a