STATE OF INDIANA COUNTY OF DELAWARE ) )SS: ) IN THE DELAWARE CIRCUIT COURT NO._____ _________________________________ Petitioner AND CAUSE NO:___________________________ __________________________________ Respondent ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT Prepared by: ________________________________ ________________________________ ________________________________ American LegalNet, Inc. www.FormsWorkflow.com ( ) ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT ( ) NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT ( ) Original ( ) Amended ( ) Termination Date: _________________________ ( ) Delaware County, Indiana ( ) Non-governmental entity or Individual ISETS Case Number: _________________ (Available from the Circuit Court Clerk’s Office) Employer’s/Income Payor’s/Withholder’sName: Employee’s /Obligor’s Name (Last, First, MI) _______________________________________ _____________________________________ Employer’s/Income Payor’s/Withholder’s Employee’s/Obligor’s SSN: Address: _______________________________________ _____________________________________ _______________________________________ _______________________________________ Employee’s/Obligor’s Cause Number: 18 C0________________________________ Employer’s / Withholder’s EIN ( if known): ______________________________________ Obligee’s / Custodial Parent’s Name ( Last , First, MI): ______________________________________ ORDER INFORMATION: This document is based on the support or withholding order from the State of Indiana. You are required by law to deduct these amounts from the employee’s/obligator’s income until further notice. $ _____________ per ______________ current child support $ _____________ per ______________ past-due child support $ _____________ per ______________ current cash medical support $ _____________ per ______________ past-due cash medical support $______________per ______________ spousal support $ _____________ per _______________ past-due spousal support $ _____________ per _______________ other (specify):__________________________ _______________________________________ for a total of $ __________________per ______________________to be forwarded to the payee below. Arrears greater than 12 wks? ( ) yes ( ) no 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: American LegalNet, Inc. www.FormsWorkflow.com $ ____________________ per weekly pay period. $ ____________________ per biweekly pay period (every two weeks). $ _______________ per semimonthly pay period (twice a month). $ ________________ per monthly pay period. REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the ISETS case number. If the employee’s/obligor’s principal place of employment is Indiana, begin withholding no later than the first pay period occurring 14 days after the date this order is received. Send payment the same day as the pay date/date of withholding. The total withheld amount, including your fee, may not exceed 50 % of the employee’s/obligor’s aggregate disposable weekly earnings. If the employee’s/obligor’s principal place of employment is not Indiana, 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 #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting payment by EFT/EDI, call (317) 232-4893 before first submission. Use this FIPS code: __________: Bank routing number: _______________________________: Bank account number: ____________________________________________________. When paying by check to the State Central Collection Unit: make check payable to “State Central Unit”, indicating on the check the ISETS identifier:_______________________ and the employee’s/obligor’s social security number: __________________________. Send check to: State Central Collection Unit P.O. Box 6219 Indianapolis IN 46206-6219 To make payments using the Child Support Bureau website, log on to www.Mychildsupport.in.gov , click on Payment Processing under Employer Services and follow the links. If this is an Order/Notice to Withhold: If this is a Notice of an Order to Withhold: SO ORDERED: _______________________ _______________________________________________ DATE JUDGE, DELAWARE CIRCUIT COURT NO:______ ( ) IV-D Agency ( ) Court ( ) Attorney ( ) Individual ( ) Private Entity ( ) Attorney with authority under state law to issue order/notice. American LegalNet, Inc. www.FormsWorkflow.com NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state’s law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the state law authorizing the attorney to issue an income withholding order/notice. IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ( ) If checked, you are required to provide a copy of this form to your employee/obligor. 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/obligor even if the box is not checked. 1. Priority: Withholding under this Order or Notice has priority over any other legal process under state law against the same income. If there are federal tax levies in effect, please notify the contact person listed below. (See 10 below). 2. Combining Payments: You may combine withheld amount 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. 3. 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/obligor’s wages. You must comply with the law of the state of the employee’s /obligor’s principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments. 4. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order or Notice against the employee/obligor and you are unable to honor all support Orders or Notices due to federal, state, or tribal withholding limits, you must follow the state or tribal law/procedure of the employee’s /obligor’s principal place of employment. You must honor all Orders or Notices to the greatest extent possible. (See 9 below). 5. Termination Notification: You must promptly notify the Child Support Enforcement (IV-D) Agency and/or the contact person listed below when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this Order or Notice to the Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See 10 below). THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR:_____________________________ EMPLOYEE’S/OBLIGOR’S NAME: _______________________________________________ CASE IDENTIFIER / CAUSE NO: 18 C0____________________________________________ ISETS CASE NO:_________________________________________________________ DATE OF SEPARATION FROM EMPLOYMENT:____________________________________ LAST KNOWN HOME ADDRESS:_________________________________________________ NEW EMPLOYER/ADDRESS:_____________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 6. 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 Child Support Enforcement (IV-D) Agency. 7. Liability: If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below under 11. If you fail to withhold income as the Order or 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 or tribal law/procedure (IC 31-16-15-23). 8. Anti-discrimination: You are subject to a fine determined under state or tribal 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 (IC 31-16-15-10 (5) (5). 9. Withholding limits: For state orders, 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. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increases by 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears greater than 12 weeks. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 10. Additional Information: You may retain a two dollar ($2.00) fee from the income payee’s income each time income withheld is forwarded. The sum total of the amount to be withheld plus this fee shall not exceed the maximum amount permitted under the Consumer Credit Protection Act. Child (ren)’s Names and Additional Information: (put additional names on back) ________________________________________DOB: _______________________ ________________________________________DOB:_______________________ ________________________________________DOB: _______________________ ________________________________________DOB: _____________________ 11. If you or your employee/obligor have any questions, contact the Delaware County Clerk’s office by telephone at 765-747-7726 or 317-232-4893. Or email Mary.Francis@fssa.in.gov. For specific and general questions regarding Indiana child support income withholding law, call (800) 292-0403. American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com