NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois County of :____________________ Case Number:_________________ Date: ________________________ ( ( ( ) ) ) Original Notice Amended Notice Terminate Notice ______________________________ Employer/Withholder's Fed. EIN No. ____________________________ Employee/Obligor's (Last, First, MI) ______________________________ Employer/Withholder's Name ____________________________ Employee/Obligor's Soc. Sec. No. ______________________________ Employer/Withholder's Address ____________________________ Court Case Number ______________________________ AND ANY SUBSEQUENT EMPLOYER ____________________________ Custodial Parent's (Last, First, MI) Child(ren)’s name (s): date of birth: Child(ren)’s ___________________ ___________ ________________ __________ ___________________ ___________ ________________ __________ ___________________ ___________ ________________ __________ name(s) date of birth: ORDER INFORMATION: This is a Notice to Withhold Income for Child Support based upon an order for support entered by the Honorable ___________________________, Circuit Court of _________________ County, IL on _____________________, 20 ___. By law, you are required to deduct these amounts from the above -named employee or obligor’s income until ________ , 20___ even if the Notice is not issued by your State. American LegalNet, Inc. www.USCourtForms.com (___) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligator'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 ______ 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 monthly pay period. $______ per biweekly pay period (every two weeks). REMITTANCE INFORMATION: Follow the laws and procedures of the employee's/obligator'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 7 working days of the paydate/date of withholding. You are entitled to deduct a fee of your actual cost not to exceed $5 monthly to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed FCCPA % of the employee/obligator's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 below): When remitting payment, provide the paydate that you withheld support and the case number: ________________. Make it payable to :______________________________________________________ Send check to :_________________________________________________________ American LegalNet, Inc. www.USCourtForms.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 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 person/agency listed below. 2. Combining Payments: 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 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 (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 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 a notice to find the allocation law of the state of the employee's principal place of employment. 5. Termination Notification: You can combine withheld amounts from more than one employee/obligator'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/obligator. You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested on the following page and return a copy of this order/notice to the person/agency. American LegalNet, Inc. www.USCourtForms.com Information Requested: EMPLOYEE'S/OBLIGOR'S NAME:________________________________________ DATE OF SEPARATION/TERMINATION OF EMPLOYMENT:___________________ LAST KNOWN HOME ADDRESS:_________________________________________ _____________________________________________________________________ _____________________________________________________________________ NEW EMPLOYER'S NAME AND ADDRESS:_________________________________ _____________________________________________________________________ Return Copy to: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ 6. Lump Sum Payments: You may 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: 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 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/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. American LegalNet, Inc. www.USCourtForms.com Protection Act (15 U.S.C.§1673 (b) ); or 2) the amounts allowed by the State of the employee/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 limit is 50% of the ADWE for child support and alimony, which is increased by : 1) 10% if the employee does not support second family; and/or 2) %5 if arrears are more than 12 weeks old (see page 1). 10. The obligor's rights, remedies and duties: see Illinois Statutes 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 and 750 ILCS 45/20. Name and address of person preparing this Notice: _______________________________________ _______________________________________ _______________________________________ _______________________________________ American LegalNet, Inc. www.USCourtForms.com