ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination Date: Connecticut State/Tribe/Territory City/Co./Dist./Reservation Non-governmental entity or individual Case Number RE: Employee's/Obligor's Name (Last, First, MI) Employer's/Withholder's Name Employer's/Withholder's Address Employee's/Obligor's Social Security Number Employee's/Obligor's Case Identifier Obligee's Name (Last, First, MI) Employer's/Withholder's Federal EIN Number (if known) . ORDER INFORMATION - This Order is based on the support or withholding order from You are required by law to deduct these amounts from the employee's/obligor's income until further notice. $ current child support Per $ yes no past-due child support - Arrears greater than 12 weeks? Per $ current cash medical support Per $ past-due cash medical support Per $ spousal support Per $ past-due spousal support Per $ other (specify) Per 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 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. REMITTANCE INFORMATION - When remitting payment, provide the pay date/date of withholding and the case identifier. If the employee's/obligor's principal place of employment is Connecticut, begin withholding no later than the first pay period occurring 14 days after the date of service or, in the case of a payer of income other than an employer, begin withholding no later than the date of periodic payment occurring 14 days after the date of service. Send payment within 7 working days of the pay date/date of % of the employee's/obligor's aggregate withholding. The total withheld amount, including your fee, may not exceed disposable weekly earnings. If the employee's/obligor's principal place of employment is not Connecticut, for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). Make check payable to: Connecticut - CCSPC (Note: CCSPC is an abbreviation for Centralized Child Support Processing Center) Send check to: Connecticut - CCSPC, P.O. Box 990032, Hartford, CT 06199-0032 If remitting payment by EFT/EDI, call 1-888-233-7223 (option 3) before first submission. Use this FIPS code: 0900003 Bank routing number code (EFT Payment): ABA 053101626 Bank account number (EFT Payment): 2000013946793 If this is an Order/Notice to Withhold: Print Name Title of Issuing Official Signature and Date IV-D Agency Court Attorney with authority under state law to issue order/notice. If this is a Notice of an Order to Withhold: Print Name Title (if appropriate) Signature and Date Attorney Individual Private Entity 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 state law authorizing the attorney to issue an income withholding order/notice. IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. JD-FM-1 Rev. 1/05 (OMB 0970-0154) Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. (To be completed by preparer) ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER 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 different from the state that issued this order, a copy must be provided to your employee/obligor even if the box is not checked. 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 below. (See #10 below.) 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 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 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 due to federal, state or tribal withholding limits, you must follow the state or 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 this Order or Notice to the Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See #10 below.) THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: EMPLOYEE'S/OBLIGOR'S NAME: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: CASE IDENTIFIER: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the Child Support Enforcement (IV-D) Agency. 7. Liability: If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below. (See #10 below.) If you 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 other penalties set by state or tribal law/procedure. Pursuant to C.G.S. § 52-362(f), you have a legal duty to make deductions from the obligor's income and pay any amounts deducted as required by this withholding order. If you do not, legal action may be taken against you. If such an action is taken, you may be liable for the full amount not withheld since receipt of proper notice. You may also be subject to a finding of contempt by the court or family support magistrate for failure to honor any terms of this withholding order. 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. Pursuant to C.G.S. § 52-362(j), if the obligor is your employee, you must not discipline, suspend, or discharge him/her because this withholding order has been served upon you. If you do unlawfully take action against your employee, you may be liable to pay such employee all of his/her lost earnings and employment benefits from the time of your action to the time that the employee is reinstated. In addition, a fine up to one thousand dollars may be imposed on any employer who discharges from employment, refuses to employ, takes disciplinary action against or discriminates against an employee subject to a support order for withholding because of the existence of such withholding order and the obligations or additional obligations which it imposes upon the employer. 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 (CCPA) (15 U.S.C. § 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, statutory pension contributions, and 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. Pursuant to C.G.S. § 52-362, certain income of the obligor cannot be withheld to satisfy this withholding order. First, only "disposable income" may be subjected to this withholding. Disposable income for the purpose of this withholding order means that part of the earnings of an individual remaining after deduction from that income of amounts required to be withheld for the payment of federal, state, and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees, and group life and health insurance premiums. Second, 85% of the first $145.00 per week of disposable income are legally exempt from this withholding order. Use the table on page 3, SECTION II, to compute the obligor's disposable income each week and the amount available for withholding. See page 3, SECTION II, for additional information on computing withholding. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who 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 Name(s) and Additional Information: 10. If you or your employee/obligor have any questions, contact: by telephone at by FAX at or by Internet at JD-FM-1 Rev. 1/05 (page 2) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. (To be completed by preparer) SECTION I (To be completed by preparer) Support Category ("X" one) A. Obligor is supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued. B. Obligor is not supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued. C. Obligor is supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued AND there is an arrearage of greater than12 weeks in length. D. Obligor is not supporting a spouse or dependent child other than the spouse or child with respect to whose support the order is issued AND there is an arrearage of greater than 12 weeks in length. SECTION II (To be completed by payer of income) ADDITIONAL INFORMATION FOR CONNECTICUT PAYERS OF INCOME Pursuant to C.G.S. § 52-362, certain income of the obligor cannot be withheld to satisfy this withholding order. First, only "disposable income" may be subjected to this withholding. Disposable income for the purpose of this withholding order means that part of the earnings of an individual remaining after deduction from that income of amounts required to be withheld for the payment of federal, state and local income taxes, employment taxes, normal retirement contributions, union dues and initiation fees, and group life and health insurance premiums. Second, 85% of the first $145.00 per week of disposable income are legally exempt from this withholding order. Use the following table to compute the obligor's disposable income each week and the amount available for withholding. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Obligor's gross income per week................................................................................................... $ Federal income tax withheld.............................................................. $ Federal employment tax.................................................................... $ State income tax withheld ................................................................. $ Local income tax withheld.................................................................. $ Normal retirement contribution .......................................................... $ Union dues and initiation fees............................................................ $ Group life insurance premium............................................................ $ Health insurance premium ................................................................ $ Total allowable deductions (add lines 2-9) ........................................ $ WEEKLY DISPOSABLE INCOME (subtract line 10 from line 1)................................................... $ Weekly Disposable Income minus 85% of the first $145.................... $ Refer to Support Category checked in SECTION I above and enter: 50% of Weekly Disposable Income if box A is checked 60% of Weekly Disposable Income if box B is checked 55% of Weekly Disposable Income if box C is checked 65% of Weekly Disposable Income if box D is checked 14. } Amount available for withholding (lesser of lines 12 and 13) $ $ The instructions below must be followed to determine the amount of weekly withholding. Refer to "Order Information" on the first page of this "Order to Withhold Income for Child Support" and line 14 above. 15. Amount of withholding - to be computed weekly: Deduct weekly the total withholding order specified in the "Order Information" on the first page or the amount specified in line 14 above, whichever is less. SECTION III (To be completed by Clerk) TO ANY PROPER OFFICER: You are hereby ordered to make due service of this Order (3 pages) on the payer of income to the obligor named on the first page of the Order. TO PAYER OF INCOME: You are hereby ordered to deduct from the income due the obligor named on the first page of the Order and to make payable as prescribed on the Order, the amount you calculated above. You are further ordered to comply with all other requirements of the Order. DATE OF COURT ORDER NAME OF JUDGE, FAMILY SUPPORT MAGISTRATE SIGNED (Judge, Family Support Magistrate, Asst. Clerk, SEO, Authorized DSS Personnel) JD-FM-1 Rev. 1/05 (page 3) DATE SIGNED Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com