Instructions for Florida Family Law Rules of Procedure Form 12.996(d), Florida Addendum to Income Withholding Order ( 07 / 13) INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12. 996 (d ) , FLORIDA ADDENDUM TO INCOME WITHHOLDING ORDER ( 07 / 13 ) When should this form be used? This form should be used when the c ourt has ordered that support be paid by income deduction and OMB Form 0970 - 0154, Income Withholding for Support, has been used. This form must be added to the OMB form to provide provisions required for income deduction orders by Florida law. This form should be typed or printed in black ink. I t should be attached to the OMB form and filed with the clerk of the circuit court in the county in which your action is pending. What should I do next? A copy of this form and a copy of the OMB Income Withholding for Support form, signed by the judge , s hould be sent to the payor by certified mail, return receipt requested. The return receipt should be sent to the person who prepared this form, so that it can be filed with the court with Florida Family Law Rules of Procedure Form 12.996(c), Noti ce of Filing Return Receipt. Where can I look for more information? - beginning of these forms. The words that are in bold underline in these instructi ons are defined there. For further information s ee section s 61.13 and 61.1301 , Florida Statutes . Special Instructions... When filling out an Income Withholding for Support form, please note the following additional instructions for that form: 1. The Remit tance Identifier is the County Code for the county the case was heard in followed by the Case Number. A list of county codes is included with these instructions. 2. The FIPS code may be found on the attached list. Use the code for the County in which the c ase is pending. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer , Florida Family Law Rules of Procedure Form 12.900(a), before h e or she helps you. A nonlawyer helping you fill out these forms American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Florida Family Law Rules of Procedure Form 12.996(d), Flor ida Addendum to Income Withholding Order ( 07/13) also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete. FIPS and County Codes COUNTY ALACHUA BAKER BAY BRADF ORD BREVARD BROWARD CALHOUN CHARLOTTE CITRUS CLAY COLLIER COLUMBIA DADE DESOTO DIXIE DUVAL ESCAMBIA FLAGER FRANKLIN GADSDEN GILCHRIST GLADES GULF HAMI L TON HARDEE HENDRY HERNANDO HIGHLANDS HILLSBOROUG H HOLMES INDIAN RIVER JACKSON JEFFERSON LAFAYETTE FIPS 12001 12003 12005 12007 12009 12011 12013 12015 12017 12019 12021 12023 12025 12027 12029 12031 12033 12035 12037 12039 12041 12043 12045 12047 12049 12051 12053 12055 12057 12059 12061 12063 12065 12067 COUNTY CODE 01 02 0 3 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 COUNTY LAKE LEE LEON LEVY LIBERTY MADISON MANATEE MARION MARTIN MONROE NASSAU OKALOOSA OKEECHOBEE ORANGE OSC EOLA PALM BEACH PASCO PINELLAS POLK PUTNAM ST. JOHNS ST. LUCIE SANTA ROSA SARASOTA SEMINOLE SUMTER SUWANNEE TAYLOR UNION VOLUSIA WAKULLA WALTON WASHINGTON FIPS 12069 12071 12073 12075 12077 12079 12081 12083 12085 12087 12089 12091 12093 12095 12097 12099 12101 12103 12105 12107 12109 12111 12113 12115 1211 7 12119 12121 12123 12125 12127 12129 12131 12133 COUNTY CODE 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 American LegalNet, Inc. www.FormsWorkFlow.com Florida Family Law Rules of Procedure Form 12.996(d ), Florida Addendum to Income Withholding Order ( 07 / 13 ) IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT, IN AND FOR COUNTY, FLORIDA Case No: Division: , Petitioner, and , Respondent. FLORIDA ADDENDUM T O INCOME WITHHOLDING ORDER TH E PAYOR , {name} , IS HEREBY NOTIFIED that, under sections 61.13 and 61.1301, Florida Statutes, you have the responsibilities and rights set forth below with regard to the Income Withholding Order/Notice for Support. 1. The Income Wit hholding O rder/Notice for Support is enforceable against employers specifically listed upon the form as well as all subsequent employers/ payors of Obligor, {name}, {address} . 2. You are required t withholding order, and in the case of a delinquency the amount specified in the notice of delinquency, and to pay that amount to the State of Florida Disbursement Unit. The amount actua lly deducted plus all administrative charges shall not be in exces s of the amount allowed under section 303(b) of the Consumer Credit Protection Act, 15 U.S.C. Section 1673(b), as amended. 3. You must implement the income deduction no later than the first pa yment date which occurs more than 14 days after the date the income deduction order was served on you, and you shall conform request at the time of the order that the payment cycle will reflect that of the obligor. 4. You must forward, within 2 days after each date the obligor is entitled to payment from you, to the to whether the amount totally or partially satisfies the periodic amount specified in the income withholding order, and the specific date each deduction is made. If the IV - D agency is enforcing the order, you shall make these notifications to the agency. 5. should have deducted, plus costs, in terest, and reasonable attorney s fees. American LegalNet, Inc. www.FormsWorkFlow.com Florida Family Law Rules of Procedure Form 12.996(d), Florida Addendum to Inc ome Withholding Order ( 07/13 ) 6. he administrative costs for the first income deduction and up to $2 for each deduction thereafter. 7. The Income Withholdi ng Order/Notice for Support is b inding on you until further notice by court order or until you no longer provide income to the obligor. 8. When you no longer provide income to the obligor, you shall notify the obligee, {name} , {address} , w payor, if known , utili zing the form contained within the Income Withholding Order/Notice for Support. If you violate this provision, you are subject to a civil penalty not to exceed $250 for the first violation or $500 for any subsequent violation. If the IV - D agency is enforcing the order, you shall make these notifications to the agency instead of the obligee. Penalties shall be paid to the obligee or the IV - D agency, whichever is enforcing the income deduction order. 9. You shall not discharge, refuse to employ, or take disciplinary action against an obligor because of the requirement for income deduction. A violation of this provision subjects you to a civil penalty not to exceed $250 for the first violation or $500 for any subsequent violation. Pen alties shall be paid to the obligee or the IV - D agency, whichever is enforcing the income deduction, if any alimony or child support obligation is owing. If no alimony or child support obligation is owing, the penalty shall be paid to the obligor. 10. The ob ligor may bring a civil action in the courts of t his state against a payor who refuses to employ, discharges, or otherwise disciplines an obligor because of income deduction. The obligor is entitled to reinstatement of all wages and benefits lost, plus re asonable attorney s fees and costs incurred. 11. In a Title IV - D case, if an obligation to pay current support is reduced or terminated due to the emancipation of a child and the obligor owes an arrearage, retroactive support, delinquency, or costs, income de duction continues at the rate in effect immediately prior to emancipation until all arrearages, retroactive support, delinquencies, and costs are paid in full or until the amount of withholding is modified. 12. All notices to the obligee shall be sent to the address provided in this notice to payor, or any place thereafter the obligee requests in writing. 13. An employer who employed 10 or more employees in any quarter during the preceding state fiscal year or who was subject to and paid tax to the Department of Revenue in a n amount of $20,000 or more shall remit support payments deducted pursuant to an inc