ORDERINOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois Co.lCity/Dist. of Ogle. Oregon, Fifteenth Date of OrderDVotice Court/Case Number Original OrdedNotice Amended OrderMotice Terminate OrderMotice ) RE: EmployerMithholder's Federal EIN Number EmployeeIObligor'sName (Last, First, MI) 1 ) EmployerMithholder's Name EmployeelObligor's Social Security Number 1 j EmployerMithholder's Address ) EmployeelObligor's* Case Identifier 1 Child(ren)'s Names: 1 1 DOB Custodial Parent's Narnc (Last, First, MI) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the ernployeelobligor'semployment. ORDER I N F O M T I O N : This is an OrderMotice to Withhold Income for Child Support based upon an Order for Support from Ogle County Circuit Court . You are required to deduct these amounts from the above-named employeelobligor's income until until further notice. $ $ Per Per $ $ $ Per Per Per for a total of $ for current support in past-due child support totaling $ Arrears 12 weeks or greater? yes in medical support in other (specify) in other (specify) 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: $ xl per weekly pay period $ x 2.165 per semimonthly pay period (twice a month) $ x2 per biweekly pay period (every two weeks) $ x 4.33 per monthly pay period REMITTANCE INFORMATION. Follow the laws and procedures of the employeelobligor'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 2working days after the date of this OrderINotice. Send payment w i t h i n 0 working days of the paydateldate 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 % of the employee/obligor's aggregate disposable weekly earnings. For the purpose your fee, cannot exceed 50 of the limitation on withholding, the following INFORMATION is needed (see #9 on next page): When remitting payment provided the paydateldate of withholding and case identifier If remitting by EFTEDI, use this F P S Code: * ;bank routing code:* bank account number: Make it payable to: State Disbursement Unit (SDU) Send check to: P. 0. Box 8000, Wheaton, IL 60189-8000 Authorized by: Print Name: Attorney of Record: American LegalNet, Inc. www.USCourtForms.com ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. Priority: Withholding under this OrderNotice 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. 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 identi@ the portion of the single payment that is attributable to each employeelobligor. Reporting the Paydatemate of Withholding: You must report the paydateldate of withholding when sending the payment. The paydateldate of withholding is the date on which the 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 support payments. Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/Notice against this employee/obligorand you are unable to honor all support OrdedNotice due to Federal or State withholding limits, you must follow the law of the state of employee'slobligor's principal place of employment. You must honor all Orders/Noticesto the greatest extent possible. (See #9 below.) Termination Notification: You must promptly noti@the payee when the employeelobligor no longer works for you. Please provide the information requested and return a copy of this OrderMotice to the agency identified below: Employee/Obligor's Name: Employee's Case Identifier: Date of Separation: Last Known Home Address: New Employer's 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. Liability: Ifyou fail to withhold income as the OrderINotice directs, you are liable for both the accumulated amount you should have withheld from the employee'slobligor'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 and fines as provided by state law. Anti-discrimination: You are subject to a fine determined under the State law for discharging an employeelobligor from employment, refusing to employ, or taking disciplinary action against any employeelobligor because of child support withholding. Withholding Limits: You may not withhold more than the lesser oE I) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. $1673(b)); or 2) the amounts allowed by the State of the employeelobligor'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 and statutory pension contnbutions. 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; andlor 2) 5% if arrears are more than 12 weeks old. (See boxes on front). For the employee/obligor's rights, remedies and duties, see Illinois Statutes 305 ILCS 5110-16.2,750 ILCS 51706.1 and 750 ILCS 45/20. Requesting Agency: If you or your employee/obligor have any questions, contact - - - - -- by telephone at: by FAX at. or by Internet: American LegalNet, Inc. www.USCourtForms.com