STATE OF INDIANA COUNTY OF HENDRICKS ) ) SS: ) IN RE: THE MARRIAGE OF _____________________________, Petitioner and _____________________________, Respondent IN THE HENDRICKS SUPERIOR COURT ______ CASE NO. 32D0___ - __________- __________ ) ) ) ) ) ) ) ) ) CHILD SUPPORT INCOME WITHHOLDING ORDER AND NOTICE TO INCOME PAYOR TO WITHHOLD INCOME Pursuant to I.C. 31-16-15, a Child Support Income Withholding Order is hereby entered and shall terminate ONLY when the support obligation, including any arrearage, ceases under Indiana Law. It is ORDERED that the amount set forth herein shall be withheld from any and all income which is or may be paid to the party in this case who is obligated to pay child support. The Employer/Income Payor is ORDERED to withhold $____________ per ___________(or the equivalent based on the pay period) not to exceed the maximum amount permitted under the Consumer Credit Protection Act (15 USC 1673 (b)). This requirement is binding until further order from the Court. The Employer/Income Payor is hereby notified that: (1) The above amount is based upon Income Payee’s Court ordered support obligation of $___________ per ______________. (2) In addition to the current support maintenance obligation, an amount of $__________ per ________to reduce an arrearage of $__________ which IS/IS NOT more than 12 weeks old. (3) The following are the maximum appropriate percentages of the disposable income that may be deducted based upon the Consumer Credit Protection Act restrictions: (A) 50% of disposable earnings for the week (pay period) because the Employee/Income Payee is supporting another spouse and/or child(ren) (other than a spouse or child(ren) with respect to whose support this order is issued). (B) 55% of disposable earnings for the week (pay period) because the Employee/Income Payee is supporting another spouse and/or child(ren) (other than a spouse or child(ren) with respect to whose support this order is issued) if the Income payee is more than 12 weeks in arrears. (C) 60% of disposable earnings for the week (pay period) because the Employee/Income Payee is NOT supporting another spouse and/or child(ren) (other than a spouse or child(ren) with respect to whose support this order is issued). (D) 65% of disposable earnings for the week (pay period) because the Employee/Income Payee is NOT supporting another spouse and/or child(ren) (other than a spouse or child(ren) with respect to whose support this order is issued) if the Employee/Income Payee is more than 12 weeks in arrears. (4) The maximum applicable percentage of disposable income to be withheld in this case is: ______ 50% _____ 55% ______ 60% ______ 65% _____ unknown. (5) Employer/Income Payor must forward the withheld income to the Indiana Child Support Bureau, State Central Unit at the address listed in this notice at the same time the income is paid. The remittance must indicate the name of the Income Payee, the name of the custodial parent, and the case number as they appear in below this order. The Employer/ Income Payor is liable for any amount of income that is not forwarded. American LegalNet, Inc. www.FormsWorkFlow.com (6) The Employer/Income Payor may retain a $2.00 fee from the Employee/Income Payee’s income each time income withheld is forwarded to the Indiana Child Support Bureau, State Central Unit. The sum total of the amount to be withheld plus this fee may not exceed the maximum amount permitted under 15 USC 1673(b). (7) The Employee/Income Payee may recover in an action at law a sum of not less than $100.00 from the Employer/Income Payor if the Employer/Income Payor discharges the Employee/Income Payee, refuses to employ the Employee/Income Payee, or disciplines the Income payee because of this order. (8) Amounts withheld under the above statute have priority over any secured or unsecured claim on income except claims for federal, state and local taxes or prior child support orders being withheld. (9) If the Employer/Income Payor is required to withhold income from more than one Employee/Income Payee that is payable to the same Clerk, the payments may be combined so long as each Employee/Income Payee’s portion is identified separately. (10)If more than 1 income withholding is in effect against a single Employee/Income Payee, the Employer/Income Payor must comply on a “first-come-first-served” basis, honoring all notices for withholding to the extent that the total amount withheld from an Employee/Income Payee’s income does not exceed the limits imposed by the Consumer Credit Protection Act. (11)Income withholding must be implemented no later than the first pay period that occurs after 14 days following the date of this notice was mailed to the Employer/Income Payor. (12)The Employer/Income Payor must notify the Court that the Income payee has terminated employment within 10 days of termination and provide to the Court the Employee/Income Payee’s last known address and the name of the new Employer/Income Payor, if known. All this ORDERED this _________ day of __________________________________________, 20___________. ___________________________________________ Superior Court Judge REMITTANCE MUST INCLUDE: ___________________________ Employer/Income Payor ____________________________________ Court Case Number ___________________________ Street/P.O. Box ____________________________________ ISETS Case Number Identifier ___________________________ Street/P.O. Box ____________________________________ Custodial Parent’s Name ___________________________ City/State/Zip Code ____________________________________ Employee/Income Payee Name/Social Security # AMOUNTS WITHHELD ARE PAYABLE TO: INDIANA CHILD SUPPORT BUREAU STATE CENTRAL COLLECTION UNIT PO BOX 6219 INDIANAPOLIS, IN 46206-6219 DATE NOTICE MAILED: _________________________________ • When paying by check, send all checks to: State Central Unite, P.O. Box 6219, Indianapolis, IN 462066219. Each check must identify the ISETS case number identifier, employee’s/obligor’s social security number, and the tribunal case number identifier. • To make payments using the free, secure Child Support Bureau website, log on to www.childsupport.in.gov click on Payment Processing under Employer Services and follow the links. Should you have any questions concerning the payment process, please call a Child Support Bureau representative at (317) 232-4893. • If making payments by electronic funds transfer (EFT/EDI), please call a Child Support representative at (317) 232-4893 before first submission. American LegalNet, Inc. www.FormsWorkFlow.com