(Rev. 7/11/05) CCDR 0556 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - DOMESTIC RELATIONS DIVISION NOTICE TO WITHHOLD INCOME FOR SUPPORT _____________________________________________ And Petitioner _________________________________________________ Respondent Case No. ______________________________________ TO: PAYOR / EMPLOYER Name / Company _______________________________ Address _______________________________________ City ___________________ County _______________ State _______________________ Zip _______________ Telephone ( ) ____________________________ Employee/Obligor's Name (Last, First, Middle) _________________________________________________________ Date of Birth _________________________ Social Security No. _________________________________________ Residential Address ______________________________________________________________________________ City _____________________ County ___________________ State ___________________ Zip ________________ Mailing Address (if different) _______________________________________________________________________ Home Telephone ( ) __________________________ Work Telephone ( ) __________________________ Driver's License No. (Illinois)_____________________ Driver's License No. (other state) _______________________ Employee Identification No. ________________________ Custodial Parent's /Obligee's Name (Last, First, Middle) _________________________________________________ Date of Birth ________________________ Residential Address ______________________________________________________________________________ City _____________________ County ___________________ State ___________________ Zip ________________ Mailing Address (if different) _______________________________________________________________________ Home Telephone ( ) __________________________ Work Telephone ( ) __________________________ Driver's License No. (Illinois)_____________________ Driver's License No. (other state) _______________________ (Page 1 of 4) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 7/11/05) CCDR 0556 B Child(ren) covered by Order For Support: Name(s) (Last, First, Middle) Sex Date of Birth ______________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ NOTICE INFORMATION: This is a Notice to Withhold Income For Support based upon the attached Order for Support, entered by the Honorable Judge _________________________________, Circuit Court of Cook County, Illinois on __________________, _______. By law, you are required to deduct the following amounts from the above-named employee's/obligor's income until _____________________, _______ even if this Notice to Withhold Income for Support is not used by your State. $ _________________ per ________________ in current support; $ _________________ per ________________ in past-due support until $ ________________ is paid in full; Arrears 12 weeks or greater? yes no $ _________________ per ________________ in medical support; $ _________________ per ________________ in other (specify): _______________________________________ $ _________________ per ________________ in other (specify): _______________________________________ Total $ _________________ per ________________ withheld to be paid over and sent to: STATE DISBURSEMENT UNIT; P.O. BOX 5400; CAROL STREAM, IL 60197-5400STATE DISBURSEMENT for payment to the obligee. 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 support payment cycle, use the following to determine how much to withhold: $ _______________ per weekly pay period. $ _______________ per semimonthly pay period (twice a month). $ _______________ per biweekly pay period. $ _______________ per monthly pay period. If checked, you are also required to immediately enroll the child(ren) identified above in any health insurance coverage available through the employee/obligor's employment, and withhold or cause to be withheld, if applicable, any required premiums. Premiums withheld shall be made to the health insurance plan in a timely manner. You are required to mail to the obligee, within 15 days of enrollment or upon request, notice of the date of coverage, specific information regarding the dependent benefits/coverage plan, and all forms necessary to obtain reimbursement for covered health expenses, such as would be made available to a new employee. When an order for dependent coverage is in effect and the insurance coverage is terminated or changed for any reason, you must notify the obligee within 10 days of the termination or change date along with notice of conversion privileges. REMITTANCE INFORMATION: Follow the laws and procedures of the State of the employee obligor's principal place of employment even if such laws and procedures are different from this paragraph: You must begin withholding no later than the first pay period occurring 14 days after the date of this notice. You must send the amount withheld to the STATE DISBURSEMENT UNIT; P.O. BOX 5400; CAROL STREAM, IL 60197-5400 within 7 business days of the pay date. You are entitled to deduct a fee of your actual cost not to exceed $5.00 per month from the income to be paid to the obligor in order to defray the cost of withholding. The total amount withheld, including your fee, cannot exceed the amount permitted under the Federal Consumer Credit Protection Act. (Page 2 of 4) (Rev. 7/11/05) CCDR 0556 C When remitting payment, provide the pay date that you withheld support; state that the order for support was entered in the Circuit Court of Cook County; Case No.__________________________; your name, address (including county), and telephone number; the obligor's name, address (including county), social security number; and driver's license number and the obligee's name, address (including county), social security number and driver's license number. ____________________________________________________ _________________________, _________ Name Date of Notice Attorney of Record Obligee ADDITIONAL INFORMATION TO EMPLOYERS/PAYORS AND OBLIGORS If checked, you are required to provide a copy of this NOTICE to your employee. TO THE PAYOR/EMPLOYER: 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 attorney or obligee listed below. 2. COMBINING PAYMENTS: You can combine withheld amounts from more than one employee/obligor's income in a single payment when sending payment to the State Disbursement Unit. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor and include his/her social security number and driver's license number. 3. REPORTING THE PAY DATE/DATE OF WITHHOLDING: You must report the pay date/date of withholding when sending the payment. The pay date/date of withholding is the date on which the employee is paid and controls the income, i.e. the date the income check or cash is given to the employee, or date on which the income is deposited directly in his/her account. 4. EMPLOYEE/OBLIGOR WITH MULTIPLE SUPPORT WITHHOLDINGS: If you receive more than one NOTICE against this employee/obligor and you are unable to honor them all in full because together they exceed the withholding limit of the State of the employee's principal place of employment you must allocate the withholding based on the law of the State of the employee's principal place of employment. If you are unsure of the State's allocation law, you must honor all NOTICE of current support withholding before you withhold for any arrearages, to the greatest extent possible under the withholding limit. 5. TERMINATION NOTIFICATION: You must promptly notify the obligee, and the Clerk of the Circuit Court when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this NOTICE to the obligee, and the Clerk of the Circuit Court. EMPLOYEE'S/OBLIGOR'S NAME: ___________________________________________________________________ EMPLOYEE'S/OBLIGOR'S CASE NUMBER: __________________________________________________________ EMPLOYEE'S/OBLIGOR'S LAST DATE OF EMPLOYMENT: ___________________________________________ EMPLOYEE'S LAST KNOWN HOME ADDRESS:_______________________________________________________ NEW EMPLOYER'S ADDRESS: ______________________________________________________________________ 6. 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. You may be found liable for the total amount which you fail to withhold or pay over and fines up to $100.00 per day for each day after the 7 day grace period. See Illinois Statutes 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 or 750 ILCS 45/20, 750 ILCS 5/507. 7. 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 child support withholding. 8. WITHHOLDING LIMITS: 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. sec. 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, including but not limited to: State, Federal, local taxes; Social Security taxes; 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 are more than 12 weeks old (see appropriate box on front). (Page 3 of 4) (Rev. 7/11/05) CCDR 0556 D TO THE OBLIGOR: 1. CONTESTING WITHHOLDING: An Obligor may contest withholding commenced by this NOTICE only by filing a petition to contest withholding with the Clerk of the Circuit Court within 20 days after service of a copy of the income withholding notice on the obligor. The grounds for the petition shall be limited. See Illinois Statutes 305 ILCS 5/10-16.2 and 750 ILCS 5/706.1. 2. MODIFY, SUSPEND, TERMINATE OR CORRECT WITHHOLDING: An obligor may petition the court, at any time, to modify, suspend, terminate or correct a withholding notice. See Illinois Statutes 305 ILCS 5/10-16.2 and 750 ILCS 5/706.1. 3. CHANGE OF ADDRESS: The obligor must notify the obligee, the public office, and the Clerk of the Circuit Court of any changes of address within 7 days. 4. CHANGE OF EMPLOYER: The obligor whose income is being withheld, or who has been served with a notice of delinquency, must notify the obligee, the public office and the Clerk of the Circuit Court of any new employer, within 7 days. 5. ANTI-DISCRIMINATION: An Obligor may not be discharged, disciplined, denied employment or otherwise penalized by a Payor because of the Payor's duty to withhold income. 6. ADDITIONAL RIGHTS, REMEDIES AND DUTIES: For the obligor's additional rights, remedies and duties, if the principal place of employment is Illinois, see Illinois Statutes 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 and 750 ILCS 45/20. Requesting Attorney: Address: _________________________________________ City/State/Zip: Phone: Fax: _________________________________ Obligee's Signature: ____________________________ Obligee's Address: ________________________________ ______________________________________ City/State/Zip: ___________________________________ ____________________________________________ Phone: _________________________________________ _____________________________________________ Fax: ___________________________________________ Atty. No. _________________________________________ (Page 4 of 4) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form