District Court Denver Juvenile Court _________________________________________County, Colorado Court Address: In re the Marriage of: in re Parental Responsibilities concerning: ________________________________________________________ Petitioner: and COURT USE ONLY Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Case Number: Document Tracking Identifier: Phone Number: FAX Number: E-mail: Atty. Reg. #: Division Courtroom INCOME WITHHOLDING FOR SUPPORT ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT TERMINATION of IWO   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 http://www.acf.hhs.gov/programs/cse/newhire/employer/publication/publication.htm#forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory__________________________Remittance Identifier (include w/payment)______________ City/County/Dist./Tribe _______________________ Order Identifier__________________________________ Private Individual/Entity _______________________ CSE Agency Case Identifier________________________ ___________________________________________RE: ___________________________________________ Employer/Income Withholder’s Name Employee/Obligor’s Name (Last, First, Middle) ____________________________________________ ____________________________________________ Employer/Income Withholder’s Address Employee/Obligor’s Social Security Number ____________________________________________ ____________________________________________ Custodial Party/Obligee’s Name (Last, First, Middle) ____________________________________________ Employer/Income Withholder’s FEIN _______________ Child(ren)’s Name(s) (Last, First, Middle) ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ JDF 1804 Income Withholding For Support R5-12 Child(ren)’s Birth Date(s) __________________ __________________ __________________ __________________ __________________ __________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ORDER INFORMATION: This document is based on the support or withholding order from __________________ (State/Tribe). You are required by law to deduct these amounts from the employee/obligor’s income until further notice. $ ____________ 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. REMITTANCE INFORMATION: If the employee/obligor’s principal place of employment is (State/Tribe), you must begin withholding no later than the first pay period that occurs days after the date of . Send payment within working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to % of disposable income for all orders. If the employee/obligor’s principal place of employment is not (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm for the employee/obligor’s principal place of employment. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit [SDU]), see http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm. Include the Remittance Identifier with the payment and if necessary this FIPS code:_____________________. Remit payment to at Family Support Registry P.O. Box 2171, Denver, CO 80201-2172 (SDU/Tribal Order Payee) (SDU/Tribal Payee Address)  Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law):___________________________________ Print Name of Judge/Issuing Official:_____________________________________________________________ Title of Judge/Issuing Official:___________________________________________________________________ Date of Signature:____________________________________________________________________________ If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe 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: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. JDF 1804 Income Withholding For Support R5-12 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor’s income in a single payment. You must, however, separately identify each employee/obligor’s portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal 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: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the “Remit payment to” instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor’s wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor’s principal place of employment regarding time periods within which you must implement 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 Tribal 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 State or Tribal law/procedure of the employee/obligor’s 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 IWO, contact the sender. If you fail to withhold income from the employee/obligor’s income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any 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 from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor’s principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTICE: 1) Pursuant to 14-14-111.5(4)(d) C.R.S., each disbursement shall be identified by the case number, the name and social security number of each obligor, the date the deduction was made, the amount of the payment, and the family support registry account number. 2) Pursuant to 14-14111.5(4)(n) C.R.S., a fraudulent submission of a Notice to Withhold Income For Support shall subject the person submitting the notice to an employer, trustee, or other payor of funds to a fine of not less than one thousand dollars and court costs and attorney fees. JDF 1804 Income Withholding For Support R5-12 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below:  This person has never worked for this employer nor received periodic income.  This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date:__________________Last known phone number: ____________________________________ Last known address:__________________________________________________________________________ Final payment date to SDU/ Tribal Payee:________________Final payment amount:_______________________ New employer’s name:________________________________________________________________________ New employer’s address:______________________________________________________________________ CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact______________________(Issuer name) by phone at , by fax at , by email or website at________________________. Send termination/income status notice and other correspondence to:___________________________________ ____________________________________________________________________________(Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact_____________________________(Issuer name) by phone at_________________________, by fax at______________________, by email or website at:______________________________________________________________________________________ _____________________________________ Signature of Attorney, if applicable Date ____________________________________________ Petitioner or Co-Petitioner/Respondent ____________________________________________ Address ____________________________________________ City, State, Zip Code ____________________________________________ (Area Code) Telephone Number (home) ____________________________________________ (Area Code) Telephone Number (work)(cell) ____________________________________________ Email CERTIFICATE OF SERVICE I certify that on ________________________ (date) a true and accurate copy of the Income Withholding for Support was served on the other party by: Hand Delivery or by placing it in the United States mail, postage pre-paid, and addressed to the following: and I certify that on __________________________ (date), I sent the original Notice to Withhold Income for Support and a certified copy of the Support Order to the Obligor’s employer by United States Mail, first class postage prepaid, addressed as follows: Date: _______________________________ JDF 1804 Income Withholding For Support R5-12 ____________________________________________ Signature Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com