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 employer in states that have adopted the Uniform Interstate Family Support Act (UIFSA) or have similar state laws. INSTRUCTIONS The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information. 1. Date the Order/Notice to Withhold is to be mailed. 2. Identifying number used by the court/agency issuing Order/Notice, if applicable. 3a-c. Check the appropriate case status of the Order/Notice to Withhold. 4a. 4b. 4c-f. Employer/Withholder’s nine-digit Federal employer identification number (if available). Include three-digit location code (if known). Employer/Withholder’s Name. Employer/Withholder’s mailing address (This may differ from the Employee/Obligor work site). 5. Employee/Obligor’s last name, first name, and middle initial (if known). 6. Employee/Obligor’s Social Security Number. 7. Case identification (or other identifier) used for recording the payment (may be the same as #2). 8. Custodial Parent’s last name, first name, and middle initial (if known). 9. Child(ren)’s name(s) and date of birth listed in the support order. ORDER INFORMATION: 10. Name of State that issued the underlying child support order. 11. Termination date of the support order. American LegalNet, Inc. www.USCourtForms.com Withholding Order Instructions page 2 of 4 12. Check if the child support order requires enrollment of the child(ren) in any health insurance coverage available to the employee’s/obligor’s employment. The space on the form is provided for your instructions to the employer, i.e. “see attached medical support form”. 13a. 13b. Dollar amount to be withheld for payment of current child support. Time period that corresponds to the amount in #13a. (e.g., month). 14a. Dollar amount to be withheld for payment of past-due child support under your State law. Time period that corresponds to amount in #14a. (e.g., month). 14b. 15a. 15b. 16a. Dollar amount to be withheld for payment of medical support, as appropriate, based on the underlying order. Time period that corresponds to amount in #15a. (e.g., month). 16b. 16c. Dollar amount to be withheld for payments of miscellaneous obligations, if appropriate based on the underlying order Time period that corresponds to amount in #16a. (e.g., month). Describe the amount(s) represented in #16a separately by the fee type (e.g., court fees). 17a. 17b. Total of #13a, #14a, #15a, and #16a. Time period that corresponds to amount in #13b. (e.g., month). 18a. 18b. 18c. 18d. Amount an employer withholds if employee is paid weekly. Amount an employer withholds if employee is paid every two weeks. Amount an employer withholds if employee is paid twice a month. Amount an employer withholds if employee is paid once a month. REMITTANCE INFORMATION: When completing numbers 19-21, please note the following: If the Order/Notice is completed for an interstate withholding, apply the law of the State of the Obligor’s principal place of employment. If the Order/Notice is completed or an interstate withholding or the employer’s agent is served with a copy in the State that issued the order, you are to follow the law of the State that issued the order. American LegalNet, Inc. www.USCourtForms.com Withholding Order Instructions page 3 of 4 19. Number of days in which the withholding must begin pursuant to the issuing State’s law. 20. Number of working days an employer or other payor of income must remit amounts withheld pursuant to the issuing State’s law. 21. Maximum percentage that can be withheld based on the applicable withholding limit of the issuing state. If the employer of a Federal agency, add the additional 5 percentage points allowed under the Federal Consumer Protection Act to the percentage entered for #18 (i.e., 65%; or 55% instead of 50% if the obligor supports a second family.), check box in the Order/Notice to indicate that support is 12 weeks or more in arrears. 22a. 22b. Case identifier or other identifier. (may be the same as #2 and/or #7). Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters that identify the State and County. If is seven characters when it identifies the State, Country and location within the County. It is necessary for centralized collections. Complete only for EFT/EDI transmission. Receiving agency’s bank routing number. Complete only for EFT/EDI transmission. Receiving agency’s bank account number. Complete only for EFT/EDI transmission. 22c. 22d. 23. Case identifier. 24a. Signature of the official(s) authorized to send the Order/Notice. This line is optional if a signature is not required by state statute. Print the name of the official(s) authorized to send the Order/Notice. 24b. 25. Check the box if the employer is to provide a copy of the Order/Notice to the employee. 26. Penalty and/or citation for any employer who fails to comply with the Order/Notice: Your State law governs unless the Obligor is employed by another State, in which the law of the State he or she is employed governs. American LegalNet, Inc. www.USCourtForms.com Withholding Order Instructions page 4 of 4 27. Penalty and/or citation for an employer who discharges, refuses to employee, or disciplines an employee/obligor as a result of the Order/Notice: 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 governs. 28. Use this space to provide the employer with additional information. 29a. Name of the agency or Court requesting the income withholding. 29b-d. Address of the agency or Court requesting the income withholding. If the employer is a Federal Government agency, the following instructions apply: • Serve the Order/Notice upon the governmental agent listed in 5 CFR part 581, appendix A. • Sufficient identifying information must be provided in Order for the Obligor to be identified. It is, therefore, recommended that the following information, if known and applicable, be provided: (1) full name of 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 obligor i.e., employee, former employee, or annuitant. • You may withhold from a variety of income and forms of payment, including voluntary separations incentive payments (buy-out payments), incentive pay, and cash rewards. 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 on 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 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. American LegalNet, Inc. www.USCourtForms.com ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois Sangamon County, Seventh Judicial District 3a__________Original Order/Notice 3b__________Amended Order/Notice 3c__________Terminate Order/Notice Date of Order/Notice__________________1 Court Case Number___________________2 4a_____________________________ Employer/Withholder’s Federal EIN Number 4b____________________________________ Employer/Withholder’s Name 4c____________________________________ Employer/Withholder’s Address 4d____________________________________ 4e____________________________________ 4f____________________________________ Child(ren)’s Name(s) : DOB RE: ) ) ) ) ) ) ) ) ) ) ) ____________________________________________5 Employer/Obligor’s Name (Last, First, MI) ____________________________________________6 Employee/Obligor’s Social Security Number ____________________________________________7 Employer/Obligor’s Case Number ____________________________________________8 Custodial Parent’s Name (Last, First, MI) Child(ren)’s Name(s): DOB 9 ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon order for support from 10_____________________. By law, you are required to deduct these amounts from the above-named employee’s/obligor’s income until _________________________.11 If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available employee’s/obligor’s employment. _______________________________________________________12 through the $13a___________per_______________13b in current support. $14a___________per_______________14b in past-due support. Arrears 12 weeks or greater? yes no $15a___________per_______________15b in medical support $16a___________per_______________16b in other (specify) __________________________________________16c for a total of $ 17a____________per________________17b to be forwarded to the payee below. $3.00 per month (or $36.00 per year) for the Circuit Clerk’s maintenance fee to be paid to Sangamon County Circuit Clerk. You do not have to vary you pay cycle to be 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.: $18a__________per weekly pay period. $18c__________per semimonthly pay period. $18b__________per biweekly pay period. $18d__________per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring 19_________ working days after the date of this Order/Notice. Send payment within 20_________ working days of the paydate/date if withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of the employee for the allowable amount. The total withheld amount, including your fee, cannot exceed 21______% of the employee’s/obligor’s aggregate disposable weekly earnings. For the purpose of the limitation of withholding, the following information is needed (see #9 on back). When remitting payment provide the paydate/date of withholding and the case identifier_________________________22a If remitting by EFT/EDI, use this FIPS code: 22b * __ __ __ __ __ __ __ __: Bank routing code:*_________________22c Make it payable to: State Disbursement Unit Send check to: P.O. Box 8000 Wheaton, IL 60189-8000 Case # :_____________________________23 Authorized by: 24a___________________________________________________________________________________________ Print Name: 24b___________________________________________________________________________________________ EFT/EDI Information American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com