AOC FORM INCOME WITHHOLDING PAGE 1 OF 6 (1) EMPLOYERINCOME WITHHOLDING FOR SUPPORT9 ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)9 ORDER/NOTICE - LUMP-SUM PAYMENTS9 TERMINATION OF IWO9 AMENDED IWODate: State/Tribe/Territory ARKANSAS Case Identifier City/County/Dist./Tribe Order Identifier Private Individual/Entity ORDER INFORMATION: This document is based on the support or withholding order from . You are required by law todeduct these amounts from the employee/obligor222s income until further notice.$ Per current child support$ Per past-due child support - Arrears greater than 12 weeks? 9 Yes 9 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 of $ Per to be forwarded to the payee below.AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle doesnot 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 periodWithhold 50% of any net lump-sum payment not to exceed the amount of the past-due child support. Remittance Information: If the employee/obligor222s principal place of employment is Arkansas, you must begin withholding no later than the first pay period that occurs 14 days after the date of this notice. Send payment within 1 working day of the pay date. If you cannotwithhold the full amount of support for any or all orders for this employee/obligor, withhold up to % (CCPA withholding limits) ofdisposable income for all orders. If the employee/obligor222s principal place of employment is not Arkansas see the ADDITIONALINFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS for limitations on withholding, applicable timerequirements and any allowable employer222s fees.9 Child Support Enforcement (CSE) Agency 9 Court 9 Attorney 9 Private Individual/Entity (Check One) NOTE: If you receive this document from someone other than a State or Tribal Child Support Enforcement agency or a court, a copy of theunderlying order that contains a provision authorizing income withholding must be attached. Or if under State law an attorney in that State,or if under Tribal law a Tribal legal representative, may issue an income withholding order, the attorney or Tribal legal representative mustinclude a copy of the State or Tribal law authorizing the attorney or Tribal legal representative to issue an income withholding order. RE: Employer/Income Withholder222s Name Employee/Obligor222s Name (Last, First, MI) Employer/Income Withholder222s Address Employee/Obligor222s Social Security Number (if known) Custodial Party/Obligee222s Name (Last, First, MI)Employer/Income Withholder222s Federal EINChild222s Name (Last, First, MI) Child222s Birth Date Child222s Name (Last, First, MI) Child222s Birth Date American LegalNet, Inc. www.FormsWorkFlow.com AOC FORM INCOME WITHHOLDING PAGE 2 OF 6For EFT/EDI instructions, contact the EFT/EDI office at the website listed below. If paying by check, make check payable to: Office of Child Support Enforcement. Include this Remittance Identifier with payment: Send check to: Arkansas Child Support Clearinghouse, P.O. Box 8125, Little Rock, AR 72203.FIPS code (if necessary): Signature (if required by State or Tribal law): Print Name: Title of Issuing Official: 9 If checked, you are required to provide a copy of this form to the employee/obligor. If your employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy must be provided to the employee/obligor even if the box is not checked. ADDITIONAL INFORMATION TO EMPLOYERS AND WITHHOLDERSState-specific information may be viewed on the OCSE Employer Services website located at:http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts.htmPriority: Withholding for support has priority over any other legal process under State law (or Tribal law if applicable) againstthe same income. If a Federal tax levy is in effect, please notify the contact person listed below.Combining Payments: You may combine withheld amounts from more than one employee/obligor222s income in a singlepayment to each agency/party requesting withholding. You must, however, separately identify the portion of the single paymentthat is attributable to each employee/obligor.Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which theamount was withheld from the employee/obligor222s wages. You must comply with the law of the State (or Tribal law ifapplicable) of the employee/obligor222s principal place of employment with respect to the time periods within which you mustimplement the withholding and forward the support payments.Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice against this employee/obligorand you are unable to fully honor all support Orders/Notices due to Federal, State or Tribal withholding limits, you must followthe State or Tribal law/procedure of the employee/obligor222s principal place of employment. You must honor all Orders/Noticesto the greatest extent possible, giving priority to current support before payment of any past-due support.Lump-Sum Payments: You may be required to withhold from net lump-sum payments such as bonuses, commissions, orseverance pay. Contact the agency or person listed below to determine if you are required to withhold or if you have anyquestions about lump-sum payments.Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. If you fail towithhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from theemployee/obligor222s income and any other penalties set by State or Tribal law/procedure.Anti-Discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor fromemployment, refusing to employ, or taking disciplinary action against an employee/obligor because of a child supportwithholding.Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer CreditProtection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor222s principalplace of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, localtaxes, Social Security taxes, statutory pension contributions, and Medicare taxes. The Federal limit is 50% of the disposableincome if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting anotherfamily. However, that 50% limit is increased to 55% and that 60% is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed thelimit indicated in this section. OMB Expiration Date - 10/31/2010. The OMB Expiration Date has no bearing on the termination date or validity of theincome withholding order; it identifies the version of the form currently in use. American LegalNet, Inc. www.FormsWorkFlow.com AOC FORM INCOME WITHHOLDING PAGE 3 OF 6Employee/Obligor222s Name: Case Identifier: Order Identifier: Employer222s Name: Arrears greater than 12 weeks? If the Order Information does not indicate whether the arrears are greater than 12 weeks,then the employer should calculate the CCPA limit using the lower percentage.For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribalemployers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction inwhich the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)).Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums