INCOME WITHHOLDING FOR SUPPORT ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT Date: TERMINATION OF IWO Child Support Enforcement (CSE) Agency Court Attorney Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions www.acf.hhs.gov/programs/css/resource/income-withholding-for-support-instructions). If you receive this document from someone other than a state or tribal CSE agency or a court, a copy of the underlying order must be attached. State/Tribe/Territory City/County/Dist./Tribe Private Individual/Entity Remittance ID (include w/payment) Order ID CSE Agency Case ID RE: Employer/Income Withholder's Name Employer/Income Withholder's Address Employee/Obligor's Name (Last, First, Middle) Employee/Obligor's Social Security Number Custodial Party/Obligee's Name (Last, First, Middle) Employer/Income 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 (State/Tribe). You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ Per current child support past-due child support - Arrears greater than 12 weeks? Yes No $ Per Per 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. Document Tracking ID OMB 0970-0154 American LegalNet, Inc. www.FormsWorkFlow.com 1 Employer's Name: Employee/Obligor's Name: CSE Agency Case Identifier: Employer FEIN: SSN: Order Identifier: REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is (State/Tribe), you must begin withholding no later than the first pay period that occurs days after the date of . Send 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. If the obligor is a nonemployee, obtain withholding limits from Supplemental Information on page 3. If the employee/obligor's principal place of employment is not (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-andprogram-information for the employee/obligor's principal place of employment. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit (SDU)), see www.acf.hhs.gov/programs/css/employers/electronic-payments. Include the Remittance ID with the payment and if necessary this FIPS code: Remit payment to at . (SDU/Tribal Order Payee) (SDU/Tribal Payee Address) 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 SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if Required by State or Tribal Law): Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: 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. 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 www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-information. Priority: Withholding for support has priority over any other legal process under State law against the same income (42 USC §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 SDU: 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 all IWOs due to federal, state, or tribal withholding limits, you must honor all IWOs 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. OMB Expiration Date - 7/31/2017. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. 2 A