CONFIDENTIAL PER HCRR RULE 9 NAME: ADDRESS: TELEPHONE NO.: [ ] Attorney for Plaintiff/Petitioner [ ] Plaintiff/Petitioner Pro Se037 [037 ] Attorneyfor Defendant/Respondent [ ] Defendant/Respondent Pro Se IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI221I ) FC255No. ) ,) [ ]ORIGINAL [ ] AMENDED [ ] Plaintiff [ ] Petitioner036 ) [ ]ONE-TIME/LUMP SUM PAYMENT v.036 )[ ]TERMINATION ORDER/NOTICE TO ) WITHHOLD INCOME FOR SUPPORT ) ,)037 [037 ] Defendant [ ] Respondent036 ) ) ) [ ] ORIGINAL [ ] AMENDED [ ] ONE-TIME/LUMP SUM [ ] TERMINATION ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT In accordance with the Americans with Disabilities Act, as amended, and other applicable stateand federal laws, if you require accommodation for a disability, please contact the ADACoordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, orvia email at adarequest@courts.hawaii.gov at least ten (10) days prior to your hearing orappointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. FC Adm 9/8/15036 Page 1 of 6 ORDER/NOTICE TO WITHHOLD INCOME 003003 American LegalNet, Inc. www.FormsWorkFlow.com INCOME WITHHOLDING FOR SUPPORT (Check One) [ ] ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) [ ] AMENDED INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT [ ] ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT [ ] TERMINATION OF INCOME WITHHOLDING ORDER Date: ~Child Support Enforcement Agency (CSEA) ~ 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/css/resource/income-withholding-for255support-instructions). If you receive this document from someone other than a State or Tribal CSEA or a Court, a copy of the underlying order must be attached. State/Tribe/Territory: City/County/Dist./Tribe: Private Individual/ Entity: Remittance Identifier (include w/ payment): Order Identifier: CSEA Case Identifier: Employer/Income Withholder222s Name RE: Employee/Obligor222s Name (Last, First, Middle) Employer/Income Withholder222s Address Employee/Obligor222s Social Security Number Custodial Party/Obligee222s Name (Last, First, Middle) Employer/Income Withholder222s FEIN: Child(ren)222s Name(s) (Last, First, Middle) Child(ren)222s Birth Date(s) (State/Tribe). You are required by law to deduct these amounts from the employee/obligor222s income until further notice. ORDER INFORMATION: This document is based on the support or withholder order from $ 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 . FC Adm 9/8/15 Page 2 of 6 ORDER/NOTICE TO WITHHOLD INCOME American LegalNet, Inc. www.FormsWorkFlow.com Employer222s Name: Employer FEIN: Employee/Obligor222s Name: SSN: CSEA Case Identifier: Order Identifier: 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 2 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/obligor222s principal place of employment is in Hawai221i, you must begin withholding no later than the first pay period that occurs 7 days after the date of mailing to you. Send payment within 5 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 (see Withholding Limits, below) of disposable income. If the obligor is a non-employee, obtain withholding limits from Supplemental Information below. If the employee/ obligor222s principal place of employment is not in Hawai221i, obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/css/resources/state-income-withholding-contacts255and-program-information for the employee/obligor222s 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/css/employers/ electronic-payments. .Include the Remittance Identifier with the payment and if necessary this FIPS code: Remit payment to the CHILD SUPPORT ENFORCEMENT AGENCY at: CHILD SUPPORT ENFORCEMENT AGENCY STATE DISBURSEMENT BRANCH P.O. BOX 1860 HONOLULU, HI 96805-1860 ~ Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to a SDU in accordance with 42 USC 247 666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to a 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):037 Print Name of Judge/Issuing Official:037 Title of Judge/Issuing Official:037 Date of Signature:037 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. FC Adm 9/8/15 Page 3 of 6 ORDER/NOTICE TO WITHHOLD INCOME American LegalNet, Inc. www.FormsWorkFlow.com Employer222s Name: Employer FEIN: Employee/Obligor222s Name: SSN: CSEA Case Identifier: Order Identifier: ADDITIONAL INFORMATION FOR EMPLOYER/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at: www.acf.hhs.gov/programs/css/resources/state-income-withholding-contacts-and-program-information. Priority: Withholding for support has priority over any other legal process under State law against the same income (42 USC 247666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to a SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor222s income in a single payment. You must, however, separately identify each employee/ obligor222s 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 a SDU (for example, payable to a 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 223Remit payment to224 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/obligor222s wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor222s 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/obligor222s 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 lu