CASE INPUT RECORD NON IV-D INCOME WITHHOLDING JD-FM-150 Rev. 4-14 C.G.S. § 52-362 Judicial district Instructions 1. See detailed instructions below. 2. Print legibly. The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/. Docket number Court location (Number, street, town and zip code) T Obligee (Person to Receive Money) T Obligor (Person to Pay Money) Name (Last, first, middle initial) Street Name (Last, first, middle initial) Street City/Town State Zip code City/Town State Zip code Telephone number Relationship to Obligor Telephone number of Obligor Telephone number of employer or payer of income Social Security number (Required - see notice below) Date of birth Sex Social Security number (Required - see notice below) Date of birth Sex M F M F Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is requested under sections 52-362 and 17b-179 of the Connecticut General Statutes. It will be used by the state child support program to ensure the proper collection, verification and distribution of support under section 17b-179 of the Connecticut General Statutes. Child(ren)'s Name(s): (As listed in support order) Date of Birth 5. 6. 7. 8. Print name Child(ren)'s Name(s): (As listed in support order) Date of Birth 1. 2. 3. 4. Signed (Preparer) Date signed Income withholding must be ordered in all child support cases. The Judicial District Clerk's Office will provide the required forms. Once the income withholding of child support orders in Non IV-D cases starts, the withheld income of the obligor (the person who owes the money) must be sent by the employer or payer of income to the State Disbursement Unit (not to the obligee) which will send the money to the obligee. You do not have to pay for the administration of Non IV-D income withholding. You must tell the Child Support Call Center of Support Enforcement Services (SES) if the obligor's employer changes and about all changes/modifications to the income withholding, including orders to end the income withholding. You must follow the instructions below whenever these types of changes occur. (SES will not enforce your order unless you ask for full IV-D services. Full IV-D child support enforcement services are available to you when you apply at a local office of the Department of Social Services. For more information about IV-D services, call the Child Support Call Center at 1-800-228-KIDS (5437).) Instructions 1. Fill out the top part of this form. Print legibly. 2. Get the Income Withholding for Support form (JD-FM-1) from the Clerk's Office, Court Service Center or on the Judicial Branch website at www.jud.ct.gov. 3. After you complete both forms, give the Income Withholding for Support (JD-FM-1) to the Clerk's Office for the clerk to review and sign. 4. After the Income Withholding for Support (JD-FM-1) is signed by the Clerk and returned to you, send it along with this form to Support Enforcement Services (SES), Child Support Call Center, P.O. Box 65, Vernon, CT 06066. This will allow SES to set up an account in the system used to track child support payments. If you do not give both forms to SES, the income withholding payments cannot be processed and disbursed to you. SES will serve, or will make sure that the Income Withholding for Support is served on the obligor's employer or payer of income. Distribution: Original - SES 5. Keep a copy of all papers for your own records. 6. If the obligor (person who owes money) did not file a written Appearance and an income withholding was ordered, you must fill out a Notice to Nonappearing Obligor of Income Withholding Order (JD-FM-70) form and have it served on the obligor. Attach proof that the JD-FM-70 was served to a copy of the JD-FM-70 form and file it with the Clerk's Office. 7. If you have any questions about the income withholding, call Support Enforcement Services (SES), Child Support Call Center at 1-800-228-KIDS (5437). Copy - For Your Records For Support Enforcement Services Only. Do not place this form in the court file. American LegalNet, Inc. www.FormsWorkFlow.com