ORDER/NOTICE TO WITHOLD INCOME FOR CHILD SUPPORT State of Illinois County/City/District of Date of Order/Notice Court Case Number Original Order/Notice Amended Terminate Order/Notice Employer/Withholder's Federal EIN Number Employee/Obligor's Name (Last, First, MI) Employer/Withholder's Name Employee/Obligor's Social Security Number Employee/Obligor's Case Identifier Employer/Withholder's Address AND ANY SUBSEQUENT EMPLOYER: Custodial Parent's Name (Last, First, MI) Child(ren)'s Name(s) and Date of Birth(s): ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from the State of Illinois. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until even if the Order/Notice is not issued by your State. 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; other (specify) $ per in medical support; $ per yes no $ per other (specify) Arrears 12 weeks or greater 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: (weekly payment x 4.33 = monthly amount, biweekly payment x 2.17 = monthly amount, and semi-monthly payment x 2 = monthly amount.) $ per weekly pay period $ per bi-weekly pay period (every two weeks) $ per monthly pay period $ per semi-monthly pay period (twice a month) 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 Order/ Notice. Send payment within 7 working days of the paydate/date of withholding. Your are entitled to deduct a fee of your actual cost not to exceed $5.00 monthly to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed 65% of the employee's/obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 on page 2): When remitting payment, indicate the paydate/date of withholding and the case identifier. If remitting EFT/EDI, use this FIPS Code: * ; Bank routing code: ; Bank account number: MAKE IT PAYABLE TO: State Disbursement Unit, P.O. Box 5400, Carol Stream, IL 60197 Authorized By: Print Name: Withhold-A (01/07) Page 1 of 2 Telephone/Cellular American LegalNet, Inc. www.FormsWorkflow.com ORDER/NOTICE TO WITHOLD INCOME FOR CHILD SUPPORT Court Case Number 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 your legal advisor for assistance. 2. COMBINING PAYMENTS: You can combine withheld amounts from more than one employee's/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, for each case. 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 amount was withheld from the employee's wages. You must comply with the law of the State of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the child support payment. 4. EMPLOYEE/OBLIGOR WITH MULTIPLE SUPPORT WITHHOLDINGS: If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/ Notice due to Federal or State withholding limits, you must follow the law of the State of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (see #9 below) 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 as the payee on the front of the form. 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 your legal advisor for assistance. 7. LIABILITY: If you fail to withhold income as the Order/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 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.S. 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 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 boxes on front) 10. For 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 NOTE: The Circuit Clerk's Office is prohibited from giving legal advice. Please contact a legal advisor for any questions or assistance that you might need. Withhold-B (01/07) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com