X ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT COURT NOTICE ORDER COUNTY .OF. . . . . . . .OF. AN . . . . . . . . TO. WITHHOLD. INCOME FOR CHILD SUPPORT ......... .. .. ... .. .......... ...... Original Amended Termination Date: : Index No. State/Tribe/Territory ARKANSAS City/Co./Dist./Reservation : Calendar No. : JUDICIAL SUBPOENA Non-governmental entity or Individual OCSE Case Number Plaintiff(s) RE: -against- : Employer's/Withholder's Name Employee's/Obligor's Name (Last,First,MI) : Employer's/Withholder's Address Employee's/Obligor's Social Security Number : Employee's/Obligor's Case Identifier Defendant(s) Obligee's Name (Last,First,MI) : ...................................................... . You are required by ORDER INFORMATION: This document is based on the support or withholding order from law to deduct these amounts from the employee's/obligor's income until further notice. Employer's/Withholder's Federal EIN Number (if known) $ $ $ $ $ $ $ Per current child support yes past-due child Per THE PEOPLE OF THE STATEsupport - Arrears greater than 12 weeks? OF NEW YORK Per Per TO Per Per Per no current cash medical support past-due cash medical support spousal support past-due spousal support other (specify) Per for a total of $ to be forwarded to the payee below. You do notGREETINGS: your pay cycle to be in compliance with the support order. If your pay cycle does not match have to vary the ordered payment cycle, withhold one of the following amounts: $ $ per weekly pay period. $ per semimonthly pay period (twice a month). WE COMMAND YOU, that all per biweekly pay period (every two weeks). business and excuses beingmonthly pay you and each of you attend before $ per laid aside, period. , the Honorable at the Court REMITTANCE INFORMATION: When remitting at located payment, provide the pay date/date of withholding and the case County of identifier. Ifin room the employee's/obligor's principal place of employment is Arkansas, begin withholdingand at any than the , on the day of , 20 , at o'clock in the noon, no later recessed days after the date of Send payment within ___ working days first pay period occurring 14 to testify and give evidence .as a witness in this action on the part of the of the pay date/date of or adjourned date, withholding. The total withheld amount, including your fee, may not exceed of the employee's/obligor's aggregate disposable weekly earnings. If the employee's/obligor's principal place of employment is not Arkansas, for limitations on withholding, applicable time requirements, Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to and any allowable employer fees, follow the laws and procedures of the employee's/obligor's the party on whose behalf this subpoena was issued for a INFORMATION TO EMPLOYERS AND OTHER principal place of employment (see #3 and #9, ADDITIONALmaximum penalty of $50 and all damages sustained as a result of WITHHOLDERS). your failure to comply. Make check payable to: Office of Child Support Enforcement Witness, HonorablePayee and Case Identifier Court in County, day of , 20 Send check to: , one of the Justices of the Arkansas Child Support Clearinghouse P.O. Box 8125 Little Rock, Arkansas 72203 (Attorney Use this FIPS type name If remitting payment by EFT/EDI, call 1-800-216-0224 before first submission. must sign above andcode: below) Bank routing number:___________________ Bank account number:___________________. If this is a Notice of an Order to Withhold: If this is an Order/Notice to Withhold: Print Name Print Name Attorney(s) for Title of Issuing Official Signature and Date X IV-D Agency Title (if appropriate) Signature and Date Court Attorney Attorney with authority under state law to issue order/notice Individual Private Entity Office and P.O. Address NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state's law, an attorney in that state may issue an Telephone to Withhold and include a copy of the income withholding order. In that case, the attorney may submit an Order/Notice No.: Facsimile state law authorizing the attorney to issue an income withholding order/notice. No.: IMPORTANT: The person completing this form is advised that the information on this E-Mail Address: with the obligor. form may be shared OMB 0970-0154 Mobile Tel. No.: OCSE - FEN31 11/04 Page 1 of 5 (1) EMPLOYER American LegalNet, Inc. www.USCourtForms.com COURT ADDITIONAL INFORMATION TO EMPLOYERS AND WITHHOLDERS If checked you are required to provide a copy of this form to your employee/obligor. If your employee works in a state that is COUNTY . . . . . . . . . . OF. . . . . . . . . . . . . . . . . . . . . . . provided . . . . different from. the. state. that issued .this .order, .a. copy. must. be . . . . . . . to. your employee/obligor even if the box is not checked. : Index No. 1. Priority: Withholding under this Order or Notice has priority over any other legal process under state law (or tribal law, if applicable) against the same income. If there are federal tax levies in effect, please notify the contact person listed below. (See 10 below.) : Calendar No. 2. Combining Payments: You may combine withheld amounts from more than one employee's/obligor's income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable : JUDICIAL SUBPOENA Plaintiff(s) to each employee/obligor. -against- : 3. Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law : of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments. : 4. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order or Notice against this employee/obligor and you are unable to honor all support Orders or Notices Defendant(s) state or tribal withholding limits, you must follow the state or due to federal, : tribal law/procedure .of .the .employee's/obligor's. principal. place .of .employment. .You must honor all Orders or Notices to the greatest ........ . .. .............. ...... .... . ......... . extent possible. (See 9 below.) 5. Termination Notification: You must promptly notify the Child Support Enforcement (IV-D) Agency and/or the contact person listed below when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of THE PEOPLE Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See 10 below.) this Order or Notice to theOF THE STATE OF NEW YORK THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: CASE IDENTIFIER: EMPLOYEE'S/OBLIGOR'S NAME: TO DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or GREETINGS: severance pay. If you have any questions about lump sum payments, contact the Child Support Enforcement (IV-D) Agency. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 7. Liability: If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below under 10. If you the Honorable at the Court fail to withhold income as the Order or Notice directs, you are liable for both the accumulated amount you should have withheld from , the employee's/obligor's income and any otherlocated at set by state or tribal law/procedure. penalties County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 8. Anti-Discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 9. Withholding Limits: For state orders, you may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection ACT (15 U.S.C § 1673(b)); or 2) the amounts allowed by the state of the employee's/obligor's principal one of the Justices of net place of employment.Witness, Honorable The federal limit applies to the aggregate disposable weekly earnings, (ADWE). ADWE is the the income left after making mandatory deductions such as: state, federal, local taxes, Social Security taxes, statutory pension contributions, and Court in County, day of , 20 Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears greater than 12 weeks. For tribal orders, you may not withhold more than the amounts allowed under (Attorney of the issuing tribe. For tribal employers who the law must sign above and type name below) receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. Child(ren)'s Names and Additional Information: 10. If you or your employee/obligor have any questions, contact: by telephone at or by internet at OCSE - FEN31 11/04 Page 2 of 5 Attorney(s) for or by Fax at Office and P.O. Address . Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com X ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT COURT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .. Original. . . . .Amended Termination Date: : Index No. ARKANSAS State/Tribe/Territory City/Co./Dist./Reservation : Calendar No. : JUDICIAL SUBPOENA Non-governmental entity or Individual OCSE Case Number Plaintiff(s) RE: Employer's/Withholder's-againstName Employer's/Withholder's Address : Employee's/Obligor's Name (Last,First,MI) Employee's/Obligor's Social Security Number : : Employer's/Withholder's Federal EIN Number (if known) Employee's/Obligor's Case Identifier Obligee's Name (Last,First,MI) Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . withholding order from ORDER INFORMATION:. This. document .is .based .on .the .support. or . . . law to deduct these amounts from the employee's/obligor's income until further notice. $ $ $ $ $ $ $ Per current child support Per past-due child support - Arrears greater than 12 weeks? . You are required by yes no THE PEOPLE OF THE STATE OF NEW YORK Per current cash medical support Per TOPer Per Per past-due cash medical support spousal support past-due spousal support other (specify) Per for a total of $ to be forwarded to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match GREETINGS: 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). business and excuses beingmonthly payyou and each of you attend before $ per laid aside, period. WE COMMAND YOU, that all the Honorable at provide the pay date/date of withholding and the case , Court REMITTANCE INFORMATION: When remitting payment, the located at of employment is Arkansas, begin withholding no later than the County of identifier. If the employee's/obligor's principal place in room on the day of , 20 , at noon, and at date/date of . Send payment withino'clock in the days of the pay any recessed ___ working first pay period occurring 14, days after the date of or adjourned date, to amount, give evidence fee, may not exceed the part of the withholding. The total withheldtestify and including youras a witness in this action onof the employee's/obligor's aggregate disposable weekly earnings. If the employee's/obligor's principal place of employment is not Arkansas, for limitations on withholding, applicable time requirements, Your failure to complyemployer subpoena is punishable as a contempt of court and will make you liable to and any allowable with this fees, follow the laws and procedures of the employee's/obligor's principal place of on whose behalf this#3 and #9, ADDITIONAL INFORMATIONofTO EMPLOYERS AND OTHER employment (see subpoena was issued for a maximum penalty $50 and all damages sustained as a the party WITHHOLDERS). result of your failure to comply. Make check payable to: Office of Child Support Enforcement Send check to: Arkansas Child Support Clearinghouse Witness, Honorable Payee and Case Identifier , one of the Justices of the Court in County, day of , 20 P.O. Box 8125 Little Rock, Arkansas 72203 If remitting payment by EFT/EDI, call 1-800-216-0224 before first submission. Use this FIPS code: (Attorney must sign above and type name below) Bank routing number:___________________ Bank account number:___________________. If this is a Notice of an Order to Withhold: If this is an Order/Notice to Withhold: Print Name Print Name Attorney(s) for Title of Issuing Official Title (if appropriate) Signature and Date Signature and Date X IV-D Agency Court Attorney Individual Private Entity Attorney with authority under state law to issue order/notice Office and P.O. Address NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state's law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/NoticeNo.: Telephone to Withhold and include a copy of the state law authorizing the attorney to issue an income withholding order/notice. IMPORTANT: The person completing this form is advised that the information on thisFacsimilebe shared with the obligor. form may No.: OMB 0970-0154 E-Mail Address: OCSE - FEN31 11/04 Page 3 of 5 Mobile Tel. No.: (2) NON-CUSTODIAL PARTY American LegalNet, Inc. www.USCourtForms.com X ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT COURT COUNTY .OF.NOTICE .OF .AN. ORDER .TO. WITHHOLD. INCOME FOR CHILD SUPPORT ......... .. ....... .. .. ....... .. .......... ..... Original Amended Termination Date: : Index No. State/Tribe/Territory ARKANSAS City/Co./Dist./Reservation : Calendar No. : JUDICIAL SUBPOENA Non-governmental entity or Individual OCSE Case Number Plaintiff(s) -against- RE: Employer's/Withholder's Name : Employee's/Obligor's Name (Last,First,MI) :Employee's/Obligor's Social Security Number Employer's/Withholder's Address : Employee's/Obligor's Case Identifier Employer's/Withholder's Federal EIN Number (if known) Obligee's Name (Last,First,MI) Defendant(s) : . . . . . . . . . . . . . . .This .document. is. based. on . the. support .or .withholding order from ... ........ . ..... .. .. ....... . .. . You are required by ORDER INFORMATION: law to deduct these amounts from the employee's/obligor's income until further notice. $ $ $ $ $ $ $ Per current child support Per THE PEOPLE OF Per Per TO Per Per Per past-due child support - Arrears greater than 12 weeks? THE STATE OF NEW YORK current cash medical support past-due cash medical support spousal support past-due spousal support other (specify) Per to be forwarded yes no for a total of $ to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match GREETINGS: the ordered payment cycle, withhold one of the following amounts: $ $ per weekly pay period. $ per semimonthly pay period (twice a month). WE pay period (every two weeks). per biweekly COMMAND YOU, that all business and excuses being monthly pay period. each of you attend before $ per laid aside, you and , the Honorable at the Court REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case located at County of identifier. If the employee's/obligor's principal place of employment is Arkansas, begin withholding no later than the in room , days day of , 20 , at o'clock in the noon, and at date/date of first pay period occurring 14 on theafter the date of . Send payment within ___ working days of the payany recessed or adjourned withheld amount, give evidence asfee, may notthis action on of the employee's/obligor's aggregate date, to testify and including your a witness in exceed the part of the withholding. The total disposable weekly earnings. If the employee's/obligor's principal place of employment is not Arkansas, for limitations on withholding, applicable time requirements,Your failureallowable employersubpoena is punishable asand procedures of and will make you liable to and any to comply with this fees, follow the laws a contempt of court the employee's/obligor's principal place of on whose behalf this #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER the party employment (see subpoena was issued for a maximum penalty of $50 and all damages sustained as a WITHHOLDERS). your failure to comply. result of Make check payable to: Office of Child Support Enforcement Send check to: Arkansas Child Support of the Witness, Honorable Payee and Case Identifier , one of the Justices Clearinghouse Court in County, day of , 20 P.O. Box 8125 Little Rock, Arkansas 72203 If remitting payment by EFT/EDI, call 1-800-216-0224 before first submission. Use this FIPS type name below) (Attorney must sign above and code: Bank routing number:___________________ Bank account number:___________________. If this is a Notice of an Order to Withhold: If this is an Order/Notice to Withhold: Print Name Print Name Attorney(s) for Title of Issuing Official Signature and Date X IV-D Agency Title (if appropriate) Signature and Date Court Attorney with authority under state law to issue order/notice Attorney Individual Private Entity Office and P.O. Address NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state's law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the Telephone No.: state law authorizing the attorney to issue an income withholding order/notice. No.: Facsimile IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. E-Mail Address: OMB 0970-0154 Mobile Tel. No.: OCSE - FEN31 11/04 Page 4 of 5 (3) COURT FILE American LegalNet, Inc. www.USCourtForms.com X ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT COURT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT COUNTY .OF .... .. .......... .... Original. . . . .Amended. . . . Termination . . Date: . . . . . . . . . . . . . . . . . . . . . . : Index No. State/Tribe/Territory ARKANSAS City/Co./Dist./Reservation : Non-governmental entity or Individual OCSE Case Number Plaintiff(s) Employer's/Withholder's-againstName Calendar No. : JUDICIAL SUBPOENA RE: : Employee's/Obligor's Name (Last,First,MI) Employer's/Withholder's Address Employee's/Obligor's Social Security Number : : Employer's/Withholder's Federal EIN Number (if known) Employee's/Obligor's Case Identifier Obligee's Name (Last,First,MI) Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . withholding order from ORDER INFORMATION:. This. document .is .based .on .the .support. or . . . law to deduct these amounts from the employee's/obligor's income until further notice. $ $ $ $ $ $ $ Per current child support Per past-due child support - Arrears greater than 12 weeks? . You are required by yes no Per current cash medical support THE PEOPLE OF THE STATE OF NEW YORK Per Per TOPer Per past-due cash medical support spousal support past-due spousal support other (specify) Per for a total of $ to be forwarded to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match GREETINGS: 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). business and excuses beingmonthly payyou and each of you attend before $ per laid aside, period. WE COMMAND YOU, that all the Honorable at provide the pay date/date of withholding and the case , Court REMITTANCE INFORMATION: When remitting payment, the located at County of identifier. If the employee's/obligor's principal place of employment is Arkansas, begin withholding no later than the in room on the day of , 20 , at noon, and at date/date of . Send payment withino'clock in the days of the pay any recessed ___ working first pay period occurring 14, days after the date of withholding. The total withheldtestify and including youras a witness in this action onof the employee's/obligor's aggregate or adjourned date, to amount, give evidence fee, may not exceed the part of the disposable weekly earnings. If the employee's/obligor's principal place of employment is not Arkansas, for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a WITHHOLDERS). result of your failure to comply. Make check payable to: Office of Child Support Enforcement Send check to: Arkansas Child Support Clearinghouse Witness, Honorable Payee and Case Identifier , one of the Justices of the P.O. Box 8125 Court in County, day of , 20 Little Rock, Arkansas 72203 If remitting payment by EFT/EDI, call 1-800-216-0224 before first submission. Use this FIPS code: (Attorney must sign above and Bank routing number:___________________ Bank account number:___________________.type name below) If this is a Notice of an Order to Withhold: If this is an Order/Notice to Withhold: Print Name Print Name Attorney(s) for Title of Issuing Official Title (if appropriate) Signature and Date Signature and Date X IV-D Agency Court Attorney Individual Private Entity Attorney with authority under state law to issue order/notice Office and P.O. Address NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state's law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the Telephone No.: state law authorizing the attorney to issue an income withholding order/notice. IMPORTANT: The person completing this form is advised that the information on thisFacsimilebe shared with the obligor. form may No.: OMB 0970-0154 E-Mail Address: OCSE - FEN31 11/04 Page 5 of 5 Mobile Tel. No.: (4) FILE COPY American LegalNet, Inc. www.USCourtForms.com