IN THE CIRCUIT COURT OF THE 22nd JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT ________________________________________ Plaintiff vs. ________________________________________ Original Amended Termination Case Number________________________________ Defendant ____________________________________________ RE:________________________________________ Employer’s/Withholder’s Name Employee’s/Obligor’s Name (Last, First MI) ____________________________________________ ___________________________________________ Employer’s/Withholder’s Address Employee’s/Obligor’s Social Security Number ____________________________________________ ___________________________________________ Employee’s/Obligor’s Case Identifier ____________________________________________ ___________________________________________ Obligee Name (Last, First MI) ____________________________________________ Employer’s/Withholder’s Federal EIN Number (if known) Children’s Name(s) Date of Birth Social Security Number ORDER/NOTICE INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an Order for Support entered by the Honorable Judge __________________________________, Twenty-Second Judicial Circuit Court of McHenry County, Illinois, on_________________________________________. By law you are required to deduct the following amounts from the above-named employee’s/obligor’s income, even if this Order/Notice is not issued by your State. $__________________ per ____________ in current support until __________________________________. $__________________ per ____________ regarding an arrearage in support until $__________is paid in full. $__________________ per ____________ regarding a delinquency in support until $_________is paid in full. [Attach computations of the period and total amount of any delinquency as of the date of the Order/Notice.] $__________________ per ____________ in medical support until _________________________________. $__________________ per ____________ in maintenance until ____________________________________. $__________________ per ____________ in other (specify):_______________________________________. TOTAL $__________________ per ____________ to be forwarded to the Payee below. The employee/obligor is supporting other dependents The employee/obligor is not supporting other dependents 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 1 : $________________ per weekly pay period $________________ per biweekly pay period $________________ per semi-monthly pay period (twice per month) $________________ per monthly pay period (once per month) 1 Weekly/Months: To convert weekly to months, multiply the weekly amount by 4.33. To convert months to weeks, divide the monthly amount by 4.33. Weekly/Semi-monthly: To convert weekly 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. CS-ORD1: Revised 12/01/06 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com If checked, you are required to enroll each child identified above as a beneficiary in any health insurance coverage available through the employee’s/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. The employer/payor shall mail to the obligee, within 15 days of enrollment or upon request, 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 obligee within 10 days of the termination or change date along with notice of conversion privileges. If checked, the parties’ written agreement providing an alternate arrangement to immediate withholding as set forth in the Support Order of _______________________________, no longer ensures payment of support due because of the reasons set forth in Exhibit _______ attached hereto. If checked, the most recent Order for Support entered does not contain the income withholding provisions required under 750 ILCS 5/706.1(b) (irrespective of whether a separate Order for Withholding was entered prior to July 1, 1997); and the obligor has accrued a delinquency after entry of the most recent Order for Support. If checked this Order/Notice shall contain a periodic amount for payment of the delinquency equal to 20% of the total of the current support amount and the amount to be paid periodically for payment of any arrearage stated in the most recent Order for Support. REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the employee’s/obligor’s principal place of employment is Illinois, begin withholding no later than the first pay period occurring 14 days after the date of _______________________. Send payment within 7 working days of the pay date/date of withholding. The total withheld amount, including your fee, cannot exceed ______% of the employee’s/obligor’s aggregate disposable weekly earnings. If the employee’s/obligor’s principal place of employment is NOT Illinois, for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee’s/obligor’s principal place of employment. If remitting payment by EFT/EDI, call 888-704-0683 before the first submission. Use this FIPS code: 17111. When remitting payment, provide the pay date that you withheld support and the following case number:___________ (Authorized) Payee:_______________________________________________________________________________ Make Checks Payable to this Name Payee’s Address:_________________________________________________________________________________ __________________________________________________________________________________ Send Checks to this Address Authorized by: (Judge – Order) _____________________________________________________________________ (Other – Notice) ____________________________________________________________________ Print Name:_____________________________________________________________________________________ Submitted by:_________________________________________________ Attorney of Record / Obligee ______________________________ Date of Order/Notice NOTE: If document is executed by Judge, enter as ORDER; if sent by other authorized person, enter as NOTICE. Requesting Attorney:_______________________________ or Obligee:__________________________________ Address:_________________________________________ Address:____________________________________ ________________________________________________ ___________________________________________ Phone:__________________________________________ Phone:_____________________________________ Fax:____________________________________________ Fax:_______________________________________ CS-ORD1: Revised 12/01/06 Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL INFORMATION TO EMPLOYERS/PAYORS AND EMPLOYEES/OBLIGORS TO THE PAYOR/EMPLOYER: 1. 2. 3. 4. 5. 6. 7. 8. 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/Notice have priority. If Federal tax levies are in effect, contact the requesting attorney or obligee listed above. Combining Payments: You can combine withheld amounts from more than one employee’s/obligor’s income in a single payment if it is sent to an authorized payee, such as the Clerk of the Circuit Court. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. Reporting the Pay Date/Date of Withholding: You must report the pay date/date of withholding when sending each payment. The pay day/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 into his or her account). 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 employee’s principal place of employment (See #8 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 the State’s allocation law, you must honor all Order/Notices’ current support withholdings before you withhold for any arrearages, to the greatest extent possible under the withholding limit. 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 payee: Employee’s/Obligor’s Name:__________________________________________________________________________ Employee’s/Obligor’s Last Date of Employment:__________________________________________________________ Employee’s/Obligor’s Last Known Home Address:________________________________________________________ New Employer’s Address:____________________________________________________________________________ Liability: If you fail to withhold income as this 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 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 Statues 305 ILCS 5/10-16.2(g), 750 ILCS 5/706.1, 750 ILCS 15/4.1 and 750 ILCS 45/20. Anti-discrimination: You are subject to a fine determined by State law for discharging an employee/obligor from employment, refusing to employ or taking disciplinary action against an employee/obligor because of support withholding. Withholding Limits: No Payor/Employer shall withhold income in excess of the lesser of the following amounts: a. b. the maximum amount permitted by Section 303(b) of the Federal Consumer Credit Protection Act (FCCPA) [15 USC 1673(b)]: 50% of the aggregate disposable weekly earnings (ADWE) if the obligor/employee is supporting other dependents; or 55% of ADWE income 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 one); or 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 payor’s/employer’s fee, may not exceed the limits specified above. ADWE is the net income left after making mandatory deductions such as State, Federal and local taxes, Social Security and Medicare taxes. TO THE OBLIGOR/EMPLOYEE 1. 2. 3. 4. 5. 6. Contesting Withholdings: An obligor may contest withholding commenced by this Order/Notice only by filing a petition to contest withholding with the Clerk of the Circuit Court within 20 days after service of a copy of the Order/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. Modify, Suspend, Terminate or Correct Withholding: An obligor may petition the Court at any time to modify, suspend, terminate or correct a withholding Order/Notice. See Illinois Statutes 305 ILCS 5/10-16.2 and 750 ILCS 5/706.1. Change of Address: The obligor must notify the obligee, the public office and the Clerk of Circuit Court of any change of address within 7 days. 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 any new payor or employer within 7 days. 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. 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. CS-ORD1: Revised 12/01/06 Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com