ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois Co./City/Dist. of ___________________________________ Date of Notice _____________________________________ Court/Case Number ________________________________ ___________________________________________________ Employer/Withholder’s Federal EIN Number ___________________________________________________ Employer/Withholder’s Name ___________________________________________________ ______________________________________________ Employer/Withholder’s Address ___________________________________________________ Any subsequent employer Child(ren)’s Name(s): DOB ________ Original Notice ________ Amended Notice ________ Terminate Notice ) ) ) ) ) ) ) ) ) ) ) ) ) RE: _____________________________________________________ Employee/Obligor’s Name (Last, First, MI) _____________________________________________________ Employee/Obligor’s Social Security Number _____________________________________________________ Employee/Obligor’s Case Identifier _____________________________________________________ Custodial Parent’s Name (Last, First, MI) Child(ren)’s Name(s): DOB ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from _____________. By law, you are required to deduct these amounts from the above-named employee’s/obligor’s income until ______________ even if the Notice is not issued by your State. *See important information Employer Summary Notice. [ ] If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee’s/obligor’s employment.____________________________________________________________________________ $_______________ per _________________ in current support $_______________ per _________________ in past due support totaling $________Arrears 12 weeks or greater? [ ] yes [ ] no $_______________ per _________________ in medical support $_______________ per _________________ in other (specify)_________________________________________________________ $_______________ per _________________ in other (specify)_________________________________________________________ for a total of $_________________ per ________________ 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 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 (every two weeks). $_________ per monthly pay period. REMITTANCE INFORMATION: Follow the laws and procedures of the employee’s/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 working days after the date of this Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduce a fee of your actual cost not to exceed $4 monthly to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed ________% of the employee/obligor’s aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 on back): When remitting payment provide the paydate/date of withholding and the case number, DeKalb County __________________________________. If remitting by EFT/EDI, use this FIPS code*: ____________; Bank routing code*: ___________________; Bank account number:___________________. Make check payable to: State Disbursement Unit Send check to: State Disbursement Unit, P.O. Box 5400, Carol Stream, IL 60197-5400 SDU Phone Number (877) 225-7077 AUTHORIZED BY : ______________________________________________________________________________________________________________ Print Name: ______________________________________________________________________________________________________________________ CH000009SUP American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [ ]If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor’s income in a single payment to each agency 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 employee is paid and controls the income, i.e. the date the income check or cash is given to the employee, or the date in which the income is deposited directly in his/her account. 4. Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/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 (see #9 below), 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 that State’s allocation law, you must honor all Orders/Notices’ current support withholdings before you withhold for any arrearages, to the greatest extent possible under the withholding limit. You should immediately contact the last agency that sent you an Order/Notice to find the allocation law of the Sate of the employee’s principal place of employment. 5. Termination Notification: You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this order/Notice to the agency identified below. EMPLOYEE’S/OBLIGOR’S NAME:_________________________________________________________________________ EMPLOYEE’S CASE IDENTIFIER:____________________________ DATE OF SEPARATION:______________________. LAST KNOWN HOME ADDRESS:__________________________________________________________________________. NEW EMPLOYER’S ADDRESS:____________________________________________________________________________. 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 person or authority below. 7. Liability: If you fail to withhold income as the Notice directs, you are liable to for both the accumulated amount you should have withheld format he employee/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 grace period. In Illinois, subsection (g) of 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 or 750 ILCS 45/20. 8. 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 a child support withholding. 9. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (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 such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. The Federal CCPA limits is 50% of the ADWE for child support and alimony, which is increase 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 boxes on front) 10. For the obligor’s 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 Agency: If you or your employee/obligor have any questions, contact: By telephone at:_______________________________________________ or By FAX at:___________________________________________________ or By Internet :____________________________________________________ CH000009SUP American LegalNet, Inc. www.FormsWorkflow.com