ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois County of Madison Date of Order/Notice Court Number: ( ( ( ) Original Order/Notice ) Amended Order/Notice ) Terminated Order/Notice RE: Payor/Withholder’s Federal EIN Number Payor/Withholder’s Name Payor/Withholder’s Address AND any subsequent Payor of Income: Child’s Name and DOB: Child’s Name and DOB: ) ) ) ) ) (Employee/Obligor’s Name: First, Last, MI) Employee/Obligor’s SS#: Employee/Obligor’s Case Identifier: Custodial Parent’s Name: Child’s Name and DOB: Child’s Name and 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 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. $ $ $ $ $ / / / / / in current support payable every two weeks in past-due support totaling $ in medical support on a total delinquency of $ as of in For a total of Arrears 12 weeks or greater? ( ) yes ( ) no 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 bi-weekly pay period (every 2 weeks) $ $ per semimonthly pay period (twice a month). 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 Order/Notice. Send payment within 7 working days of the pay date/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 65% of the employee/obligor’s aggregate disposable weekly earning. For the purpose of the limitation on withholding, the following information is needed (see #9 on back): When remitting payment provide the pay date/date of withholding, the Court/Case Number . If remitting by EFT/EDI, use this FIPS code: N/A ; Bank routing code: and the case identifier N/A ; Bank account number: N/A . Make checks payable to and send to: State Disbursement Unit P.O. Box 5400 Carol Stream, IL 60197 Court Case: and Case Identifier: Authorized by: Print Name: D PA 3683 (7/97) Page 1 of 2 IL4782408 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 withholding 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 state 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: 6. NEW PAYOR’S (OF INCOME) NAME AND ADDRESS: 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 Order/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 failed 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 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 (1 5 U.S.C. § 1673(b)); or 2) the amount 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. Obligor’s Rights: 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. Requesting Agency: DPA 3683 (7/97) Madison County Circuit Clerk 155 North Main Street Edwardsville, IL 62025 Page 2 of 2 If you or your employee/obligor has any question, contact the Child Support Section of the Circuit Clerk at telephone (618) 692-6250 or FAX (618) 692-8904 IL 4782408 Case No. ________________ American LegalNet, Inc. www.FormsWorkFlow.com Document Handbook Instructions for Completing DPA 3683, Order/Notice to Withhold Income for Child Support CSE The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. Submit the Order/Notice to employers in States that have adopted the Uniform Interstate Family Support Act (UIFSA) or have similar State laws. The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information. Item 1 Description Name of your county. 2 Date the Order/Notice to Withhold is to be mailed. 3 Tribunal number (administrative or docket) used by the court/agency issuing this Order/Notice, if appropriate. 4 Check the appropriate case status of the Order/Notice to Withhold: a. original (or) b. amended (or) c. terminate 5 Employer/Withholder’s nine-digit Federal Employer Identification Number (FEIN), if available. Include three-digit location code, if known. 6a Employer/Withholder’s name 6 b-d. Employer/Withholder’s mailing address (may differ from the Employee/Obligor work site). 6e This entry ensures that if the employee changes jobs, this Notice can be served on the “subsequent employer.” 7 Employee/Obligor’s last name, first name and middle initial (if known). 8 Employee/Obligor’s Social Security number. 9 IV-D number used for recording the payment (may be the same as #3.) 10 Custodial parent’s last name, first name and middle initial (if known). 11 Child(ren)’s name(s) and date(s) of birth as listed in the support order. 12 Name of state that issued the underlying (original jurisdiction) child-support order. 13 Termination date of the support order. 14 Check if the child-support order requires enrollment of the child(ren) in any health insurance coverage available through the employee’s/obligor’s employment. If the obligor is a Federal INCOME WITHHOLDING DOCUMENT #38 American LegalNet, Inc. www.FormsWorkFlow.com Item Description government employee, please do not check the box provided. The space is provided for instructions (i.e., see attached form). 15a. Dollar amount to be withheld for payment of current child support. If no current support is ordered enter the word “none.” 15b. Time period (frequency due) that corresponds to the amount in #15a (e.g., month). 16a. Dollar amount to be withheld (including frequency due) for payment of past-due child support under State law (if a dollar amount is involved pursuant to a Notice of Delinquency or an established arrearage). If none is ordered, enter the word “none.” If additional space is needed, go to item 18 or 19. 16b Time period (frequency due) that corresponds to the amount in 16a (e.g., month). 16c Total amount of past-due support. 17a For medical support, as appropriate, based on the underlying order enter the work “premium.” If none is ordered, enter the word “none.” 17b Time period (frequency due) that corresponds to the amount in 17a (e.g., monthly, weekly or “premium schedule”). 18a Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order. If none, enter the word “none.” 18b Time period (frequency due) that corresponds to the amount in 18a (e.g., month). 18c Describe the delinquency amount(s) by adding the following statement on the blank line: $ per month on a total delinquency of $ . 19a Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order and time period that corresponds to the amount in 19a. 19b Time period (frequency due) that corresponds to the amount in 19a (e.g., month). 19c Describe the amount(s) represented in 19a separately by fee type (e.g., court fees). 20a Total of 15a, 16a, 17a, 18a, and 19a. 20b Time period (frequency due) that corresponds to the amount in 15b (e.g., month). 21 Check this box if arrears are 12 weeks or greater. 22a Amount an employer withholds if the employee is paid weekly. 22b Amount an employer withholds if the employee is paid every two weeks. INCOME WITHHOLDING DOCUMENT #38 American LegalNet, Inc. www.FormsWorkFlow.com Item Description 22c Amount an employer withholds if the employee is paid twice a month. 22d Amount an employer withholds if the employee is paid once a month. 23 Number of days in which the withholding must begin pursuant to the law of your State. 24 Number of working days an employer or other payor of income must remit amounts withheld pursuant to the law of your State. 25 Maximum percentage that can be withheld based on the applicable withholding limit of your State. If the employer is a Federal agency and you add the additional five percentage points allowed under the Federal Consumer Credit Protection Act to the percentage entered for #22 (i.e., 65%; or 55% instead of 50% if the obligor supports a second family), check #14c on the Order/Notice to indicate the support is 12 weeks or more in arrears. 26a IV-D number or other identifier (may be the same as #3 and/or #9). 26b Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters and identifies the State and county. It is seven characters when it identifies the State, county and a location within the county. It is necessary for centralized collections. Complete only for EFT/EDI transmission. 26c Receiving agency’s bank routing number, to be completed only for EFT/EDI transmission. 26d Receiving agency’s bank account number, to be completed only for EFT/EDI transmission. 27a Name of child-support enforcement agency to which payments are made and the IV-D case number on payment line. 27b-d Street address, city and state of the child-support enforcement agency identified in #28a. 28a Signature of official(s) authorized to send the Order/Notice. This line is optional if signature is not required by State statute. 28b Print name of the official(s) authorized to send the Order/Notice. 29a Name of attorney of record. 29b Registration number for attorney of record. 30 Check the box if the employer is to provide a copy of the Order/Notice to the employee. If you are serving this order out of the State of Illinois, this box must be checked. 31 Penalty and your state citation for an employer that fails to comply with the Order/Ntoice. Your State law governs unless the obligor is employed in another state, in which case the law of the state in which he or she is employed. 32a Name of the agency or court requesting the income withholding. INCOME WITHHOLDING DOCUMENT #38 American LegalNet, Inc. www.FormsWorkFlow.com Item Description 32b-e Address of the agency or court requesting the income withholding. 33a Name of the child-support enforcement agency’s contact person who an employer and/or employee/obligor may call for information regarding the Order/Notice. 33b Telephone number of the contact person who an employer may call for information regarding the Order/Notice. 33c Facsimile number for the person whose name appears in #35a. 33d Internet address for the person whose name appears in #35a. If the employer is a Federal government agency, the following instructions apply: Serve the Order/Notice upon the governmental agent listed in 5CFR part 581, appendix A. Sufficient identifying information must be provided in order fro the obligor to be identified. It is, therefore, recommended that the following information, if known and if applicable, be provided: 1) full name of the obligor; 2) date of birth; 3) employment number, Department of Veterans Affairs claim number, or civil service retirement claim number; 4) component of the government entity for which the obligor works, and the official duty station or worksite; and 5) status of the obligor, e.g., employee, former employee, or annuitant. You may withhold from a variety of income and forms of payment, including voluntary separation incentive payments (buyout payments), incentive pay, and cash awards. For a more complete list, see 5 CFR 581.103. ******************************** The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 45 CFR 303.7 of the child-support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Income Withholding Document #38 American LegalNet, Inc. www.FormsWorkFlow.com