INCOME WITHHOLDING FOR SUPPORT o ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) o AMENDED IWO o ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT o TERMINATION of IWO Date: _ _ _ _ _ __ I DChiid Support Enforcement (CSE) Agency 0 Court 0 Attorney DPrivate Individual/Entity (Check One) i NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the ~ ~:=~~=~~~~;~~:~~~~i=~~~~M must be attached. .. .. .. StatelTribelTerritory City/County/Dist.lTribe _ _ _ _ _ _ _ __ Private Individual/Entity _ _ _ _ _ _ _ __ Remittance Identifier (include w/payment) _ _ _ _ _ _ _ __ Order Identifier_--:-:-~=-_ _ _ _ _ _ _ _ _ _ _ _ __ CSE Agency Case Identifier _ _ _ _ _ _ _ _ _ _ _ __ RE: Employerllncome Withholder's Name Employee/Obligor's Name (Last, First, Middle) Employerllncome Withholder's Address Employee/Obligor's Social Security Number Custodial Party/Obligee's Name (Last, First, Middle) Employerllncome Withholder's FEIN _ _ _ _ _ __ Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) ORDER INFORMATION: This document is based on the support or withholding order from =--:.,..----;-0--- (State/Tribe). You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ current child support _ _ _ _ _ _ past-due child support - Arrears greater than 12 weeks? DYesD No current cash medical support $ _ - - - - - Per _ _ _ _ _ _ past-due cash medical support Per current spousal support $ Per past-due spousal support $ Per other (must specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ for a Total Amount to Withhold of $ per _ _ _ _ _ __ AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ per weekly pay period $ per semimonthly pay period (twice a month) $ per biweekly pay period (every two weeks)$ per monthly pay period $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMA TlON: If the employee/obligor's principal place of employment is (StatelTribe), . Send you must begin withholding no later than the first pay period that occurs _ _ days after the date of payment within __ working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to __ % of disposable income for all orders. If the employee/obligor's principal place of employment is not (StatelTribe), obtain withholding limitations, time requirements, and any allowable employer fees atbltp;//W'N.'.:Y~~,bh~,gQy.lprQ.gr£\rl1s/G$f:.!neVibjr.f:.I~mRJQYf;r/GQDJqQ.t.§lcQotaGLm;;!pJJtm for the employee/obligor's principal place of employment. Document Tracking Identifier _ _ _ _ _ _ _ _ _ _ _ _ _ __ OMS 0970-0154 American LegalNet, Inc. www.FormsWorkFlow.com For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursem ent Unit [S DU]), see httJ:2:LLw.ww..aQt.b.h.§,gO.w'.PIQ9[?mslC$.e.lnewhjr~t.~mplQye.J1CQJltgct.§/CQ!Jt~cUn~p~Qtm. Include the Remittance /dentifierwith the payment and if necessary this FIPS code: ~emit~b~gx SqcJ- L~~~stteAm\":t:L fPo\Q1-SqQt) _---"L=-:e~e=-_Qo=-::::..u.=(\...:....!.3rf-f-_ (SDUlTribal Order Payee) (SDUlTribal Payee Address) o Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDUlTribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judgellssuing Official (if required by State or Tribal law): Print Name of Judgellssuing Official: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ TWe~JudgelissuingOfficial: _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date of Si nature: If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. D If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at: mm:llwww.acf.hhs.gov/programs/c.s~fn.ewhire/employer/CQm~ts/contacLmap.htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7». If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/obligor's portion of the payment. Payments To SOU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor alilWOs due to Federal, State, or Tribal withholding limits, you must honor alilWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/ obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. OMS Expiration Date - 05/31/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the fonn currently in use. American LegalNet, Inc. www.FormsWorkFlow.com Employer's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Employer FEIN: ________________ Employee/Obligor's Name: _ _ _ _ _ _ _ _--::---:---:--:---:-:::-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ CSE Agency Case Identifier: _ _ _ _ _ _ _ _ Order Identifier: _____________________ 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. 1673(b»; or 2) the amounts allowed by the State or Tribe of the employee/ obligor's principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b». Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: o This person has never worked for this employer nor received periodic income. o This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: __________________ Last known phone number: Last known address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ Final payment date to SOUl Tribal Payee: ________ Final payment amount: _ _ _ _ _ _ _ _ _ __ New employer's name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ New employer's address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _--'-_ _ _ _ _ __ CONTACT INFORMATION: To Employerllncome Withholder: If you have any questions, contact _-:--:---:-_ _ _ _ _ _ _ _ (Issuer name) by phone at , by fax , by email or website at: _______________ Send termination/income status notice and other correspondence to: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact,...,..,...-..--:-r;---::-,,--_ _ _ _ _ _ _ _ (Issuer name) by phone at , by fax at , by email or website at -------------- IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. American LegalNet, Inc. www.FormsWorkFlow.com