ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination State Co./City/Dist. of Tribunal/Case Number Employer’s/Withholder’s Name Employer’s/Withholder’s Address Child(ren)’s Name(s): DOB Employer/Withholder’s Federal EIN Number (if known) RE: Employee’s/Obligor’s Name (Last, First, Mi) Employee’s/Obligor’s Social Security Number Employee’s/Obligor’s Case Identifier Obligee Name (Last, First, Mi) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available to the employee/obligor through his/her employment. ORDER INFORMATION: This Order/Notice is based on the support order from You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice. $ per Current child support $ per Past-due child support-Arrears 12 weeks or greater? $ per Current medical support $ per . Past-due medical support $ per per no Spousal support $ yes Other (specify) for a total of $ per 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 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. 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 , begin withholding no later than the first pay period occurring days after the date of . Send payment within 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 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 (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting payment by EFT/EDI, call Bank routing code: before first submission. Use the FIPS code: Bank account number: Make check payable to: Send check to: Payee and Case identifier Authorized by Date: Date: Print Name and Title of Authorized Official(s) IMPORTANT: The person completing this form is advised that the information on this may be shared with the obligor. 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. If your employee works in a state that is difference from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned business, and Indianowned businesses located on a reservation that choose to withhold in accordance with this notice. 2. 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 State Child Support Enforcement Agency or party listed in number 12 below. 3. Combining Payments:You can combine withheld amounts from more than one employee’s/obligor’s income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 4. Reporting the Pay Date/Date of Withholding: You must report the pay date/date of withholding when sending the payment. The pay date/date 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. 5. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee’s/obligor’s principal place of employment. You must honor all Order/Notices to the greatest extent possible. (see #10 below.) 6. Termination Notification: You must promptly notify the Child Support Enforcement Agency or payee when the Employee/obligor no longer works for you. Please provided the information requested and return a complete copy of this Order/notice to the Child Support Enforcement Agency or payee. EMPLOYEE’S/OBLIGOR’S NAME: CASE IDENTIFIER: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: 7. 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. 8. Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. 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’s/obligor’s income and any other penalties set by State law. 9. 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 a child support withholding. 10. Withholding Limits: You may not withhold more than the lesser of: 1) 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 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, statutory pension contributions, and Medicare taxes. Additional Information: 11. Submitted by 12. If you or your employee/obligor have any questions, contact:_______________________________________________ by telephone at __________________________________ or by FAX at ______________________________________ or by Internet at ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com