District Court Juvenile Court _____________________________ County, Colorado Court Address: In re: The Marriage of: Parental Responsibilities concerning: ______________________________________________________ Petitioner: and COURT USE ONLY Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom NOTICE TO WITHHOLD INCOME FOR SUPPORT Date of Notice: ____________________________________ To: Name of Employer, Trustee, or Other Payor of Funds: _______________________________________ Address: ___________________________________________________________________________ Phone Number: ____________________________________ Colorado employers, trustees, or other payors of funds must comply with §14-14-111.5, C.R.S. Re: Name of Obligor: ________________________________Social Security Number: _________________ Family Support Registry (FSR) Account Number: ____________________________________________ Name of Obligee: ____________________________________________________________________ Full Name of Child Date of Birth Notice Information. This is a Notice to Withhold Income for Support based upon an order for support from ______________________________________. By law, you are required to deduct these amounts from the above-named employee’s/obligor’s income until you are notified in writing by the Obligee, Obligee’s representative, the child support enforcement unit, or the Court, even if the Notice is not issued by your State. If checked, you are required to enroll the child(ren) identified above in any health/dental insurance coverage available through the employee’s/obligor’s employment. JDF 1804 R11/06 NOTICE TO WITHHOLD INCOME FOR SUPPORT Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com The total monthly obligation is as follows: $____________ per month in current child support $____________ per month in past due support at ________ % interest (1/24th of total) $____________ per month in current maintenance $____________ per month in past due maintenance at ________ % interest (1/24th of total) $____________ per month in medical/dental support Total monthly payment 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 the monthly ordered support payment cycle, use the following to determine how much to withhold: Note: Colorado state law requires that you divide the withholding among the pay periods for the month, but the total amount withheld in a month must equal the monthly amount due as specified on the income assignment. $____________ per weekly pay period $____________ per biweekly pay period (every two weeks) $____________ per semimonthly pay period (twice a month) $____________ per monthly pay period Remittance Information You must begin withholding no later than the first pay period occurring 14 working days after the date of this Notice. Send payment within 7 working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of the employee for the allowable amount. The total withheld amount, including your fee, cannot exceed 65% of the employee’s/obligor’s aggregate disposable weekly earnings, (see #9). Mail to the Family Support Registry or P. O. Box 2171 Denver, CO 80201-2171 Include the pay date, date of withholding, and FSR number. Mail directly to the Obligee at this address: __________________________________________ __________________________________________ Additional Information to Employers and other Withholders If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding under this Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this notice have priority. If there are Federal tax levies in effect please contact the requesting Federal agency. 2. Combining Payments: You can combine withheld amounts from more than one employee’s/obligor’s income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 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 notice and forward the support payments. JDF 1804 R11/06 NOTICE TO WITHHOLD INCOME FOR SUPPORT Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com 4.* Employee/Obligor with Multiple Support Withholdings: If there is more than one Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Notices due to Federal or State withholding limits, you must follow the law of the state of employee’s/obligor’s principal place of employment. You must honor all Notices to the greatest extent possible. (see #9) 5. Termination Notification: You must promptly notify, in writing, the payee or the FSR, if payments are made through the FSR, when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Notice to the payee or the FSR, if applicable. Employee’s/Obligor’s Name: ___________________________________________________________ Employee’s Case Identifier: _________________________ Date of Separation: ___________________ Last Known Home Address: _____________________________________________________________ New Employer’s Name & Address: ________________________________________________________ 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. 7. Liability: If you fail to withhold income as the Notice directs, you are liable for both the accumulated amount you should have withheld from the employee's/obligor’s income and any other penalties set by State law. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 USC §1673 (b); or 2) the amounts allowed by the State of the employee’s/obligor’s principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. *NOTE: If you or your agent are served with a copy of the order in the state that issued the notice you are to follow the law of the state that issued the order with respect to these items. NOTICE: 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. (§14-14-111.5(4)(n) C.R.S.) CERTIFICATE OF MAILING 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: and I certify that I sent a copy of the Notice to Withhold Income for Support and a certified copy of the Support Order to the Obligor by United States Mail, first class postage prepaid, addressed as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ and I certify that I filed a copy of the Notice to Withhold Income for Support with the Court. Date: _______________________________ _____________________________________ Signature (Obligee or Obligee’s Representative) JDF 1804 R11/06 NOTICE TO WITHHOLD INCOME FOR SUPPORT Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com