IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) ) ) ) ) Petitioner, Respondent. Original Notice Amended Notice Termination Notice Gen. No. NOTICE TO WITHHOLD INCOME FOR SUPPORT TO: Employer/Withholder’s Name Employer/Withholder’s FEIN Employer/Withholder’s Address RE: Employee/Obligor’s Name (Last, First, MI) Employee/Obligor’s Social Security Number* Custodial Parent/Obligee’s Name (Last, First, MI) Custodial Parent/Obligee’s Social Security Number* Child(ren)’s Name(s) Birth date Social Security Number* ORDER INFORMATION: This is a Notice to Withhold Income for Support based upon an Order for Support from the Circuit Court of Lake County, Illinois dated . By law, you are required to deduct these amounts from the above-named employee/obligor’s income until even if the Notice is not Arrears 12 weeks or more? issued by your state. yes no $ per in current support $ per in past due support in the amount of $ $ per in medical support $ per in delinquent child support payments $ per in other (specify) $ per in other (specify) for a total of $ per The employee/obligor is supporting other dependents? yes no to be forwarded to the State Disbursement Unit. If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee/obligor’s employment, trade or labor union. See ¶ 10 on page 3 for further instructions on your obligation to deduct for health insurance. 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 Page 1 of 4 171-60a 9/04 American LegalNet, Inc. www.USCourtForms.com 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. * Note: Weeks/Months: To convert weeks to months, multiply the weekly amount by 4.33. To convert months to weeks, divide the monthly amount by 4.33. Weeks/Semi-monthly: To convert weeks to a semi-monthly pay period, multiply the weekly amount by 2.17. To convert a semi-monthly pay period to weeks, divide the semi-monthly amount by 2.17. Biweekly/Semi-monthly: To convert a biweekly pay period to a semi-monthly pay period multiply the biweekly amount by 1.08. To convert a semi-monthly pay period to a biweekly pay period divide the semi-monthly pay period by 1.08. REMITTANCE INFORMATION: Under Illinois law, you must begin withholding no later than the next payment of income to the employee/obligor that occurs 14 business days after the date of this Notice. You must send the amount withheld to the payee within 7 business days of the pay date. You are entitled to deduct a fee for your actual cost not to exceed $5.00 monthly to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed the amount permitted under the Federal Consumer Credit Act. See ¶ 9 on page 3 for limitations on the total amount that can be withheld. When remitting payments provide: (1) the pay date/date of withholding and (2) the general number: Make check payable to: State Disbursement Unit Send check to: State Disbursement Unit, Post Office Box 5400, Carol Stream, Illinois 60197 Authorized by: Print Name: 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 Notice 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’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. 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 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 payments. 4.** Employee/Obligor with Multiple Support Withholdings: If there is more than one Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Notices 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 Notices to the greatest extent possible (see ¶ 9 below). 5. Termination Notification: You must promptly notify the State Disbursement Unit when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Notice to the agency identified below. EMPLOYEE/OBLIGOR’S NAME: CASE GENERAL NUMBER: DATE OF SEPARATION: EMPLOYEE/OBLIGOR’S 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. Page 2 of 4 171-60a 9/04 American LegalNet, Inc. www.USCourtForms.com 7. Liability: If you fail to withhold income as this 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 by state law. Under Illinois law, you may be found liable for the total amount that you fail to withhold and pay over and fines of $100 per day for each day after the 7 day grace period. (See Illinois Statutes 305 ILCS 5/10-16.2(G), 750 ILCS 15/4.1 and 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: No employer/payor shall withhold income in excess of the lesser of the following amounts: (1) the maximum amount permitted by Section 303(b) of the Federal Consumer Credit Protection Act [15 USC 1673(b)]: 50% of the aggregate disposable weekly earnings (ADWE) if the employee/obligor is supporting other dependents; or 55% of ADWE if the employee/obligor is supporting other dependents and the arrearage is owed for 12 weeks or more; or 60% of ADWE if the Employee/obligor is not supporting other dependents; or 65% of net income if the Employee/obligor is not supporting other dependents and arrearage is owed for 12 weeks or more (see appropriate boxes on page 1) or (2) the amounts allowed by the state of the employee’s/obligor’s principal place of employment. The total amount withheld from the employee’s/obligor’s income, including the employer/payor fee, may not exceed the limits specified above. ADWE is the net income left after making mandatory deductions such as: state, federal, local taxes, Social Security and Medicare taxes. 10. Health Insurance Coverage: If you are required to enroll each child identified above as a beneficiary in any health insurance coverage available through the employee/obligor’s employment, you are also required to withhold or cause to be withheld, if applicable, any required premiums and pay over any amounts so withheld and any additional amounts the employer pays to the insurance carrier in a timely manner. Within 15 days of enrollment, or upon request, the employer/payor shall mail to the custodial parent at the address listed below a notice of the date of coverage, information on the dependent coverage plan and all forms necessary to obtain reimbursement for covered health expenses, such as would be made available to a new employee. When the insurance coverage is terminated or changed for any reason, the employer/payor shall notify the custodial parent within 10 days of the termination or change date along with notice of conversion privileges. Name of custodial parent: Address of custodial parent: ** Note: If you or your agent are served with a copy of this Notice in the state that issued the Notice, you are to follow the law of the state that issued this Notice with respect to these items. TO THE EMPLOYEE/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 of Lake County, Illinois, within 20 days after service of a copy of the Notice to Withhold Income 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 any time to modify, suspend, terminate or correct a Notice to Withhold. (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 Court of Lake County, Illinois, of any change of address within 7 days. 4. Change of Payor: 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 Lake County, Illinois, of any new payor or 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. 7. Withholding Initiated Pursuant to 750 ILCS 706.1(D): If checked, the parties written agreement providing an alternate , no longer ensures arrangement to immediate withholding as set forth in the support order dated payment of support due to the following reasons: 8. Payment of Delinquency: If checked, a delinquency has accrued since the entry of the most recent Order for Support. As Page 3 of 4 171-60a 9/04 American LegalNet, Inc. www.USCourtForms.com of the date of this Notice, the amount of the delinquency is $ . The Notice to Withhold Income shall contain a periodic payment of the delinquency in an amount equal to 20% of the total of the amount of current support and the amount to be paid periodically for payment of any arrearage stated in the Order for Support. The delinquency is computed as follows: This notice to withhold is submitted pursuant to the Income Withholding for Support Act by: Obligee†: Requesting Agency: (contact information must be completed) Signature Name of Public Office Printed Authorized Representative † The obligee must notify the State Disbursement Unit, within 7 days, of a change of address. If you or your employee/obligor have any questions, contact: by telephone at or by Internet at or by FAX at . DEFINITIONS EMPLOYER/PAYOR: Any payor of income to an obligor. FREQUENCY OF PAYMENTS: Weekly — Every week on the same day. Bi-weekly — Every other week on the same day. Semi-monthly — Two different days of the month fifteen days apart. Monthly — Once a month on the same day. Yearly — Once a year on the same day. GUIDELINE PERCENTAGES OF NET INCOME PER NUMBER OF CHILDREN: 1-20%, 2-28%, 3-32%, 4-40%, 5-45%, 6 or more-50%. NET INCOME: The total of all income from all sources, minus the following deductions: a) Federal income tax (properly calculated withholding or estimated payments) b) State income tax (properly calculated withholding or estimated payments) c) Social Security (FICA payments) d) Mandatory retirement contributions required by law or as a condition of employment e) Union dues f) Dependent and individual health/hospitalization insurance premiums g) Prior obligations of support or maintenance actually paid pursuant to a court order h) Expenditures for repayment of debts that represent reasonable and necessary expenses for the production of income, medical expenditures necessary to preserve life or health and reasonable expenditures for the benefit of the child and the other parent, exclusive of gifts. The court shall reduce net income in determining the maximum amount of support to be ordered only for the period that such payments are due and shall enter an order containing provisions for its self-executing modification upon termination of such payment period. OBLIGEE: An individual to whom a duty to support is owed or the individual’s legal representative. OBLIGOR: An individual who owes a duty to make support payments under an order for support. TERMINATION OF CHILD SUPPORT: The date the youngest child reaches 18 or graduates high school, whichever is later. *NON CITIZENS: Provide alien registration number, passport number and home country’s social security number or national health number. NOTE: THIS DOCUMENT MUST BE COMPLETED IN TRIPLICATE Page 4 of 4 171-60a 9/04 American LegalNet, Inc. www.USCourtForms.com