ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT/MAINTENANCE ___ Original ___ Amended ___ Termination State: KANSAS Co./City/Dist. Of WYANDOTTE/KANSAS CITY Case Number: WYCase Number Employer’s/Withholder’s Name Employer’s/Withholder’s Address Employer’s/Withholder’s City, State Zip RE: Employee’s/ Obligor’s Name -- OBLIGOR Employee’s/Obligor’s SS # Employee’s/Obligor’s Case Number Child(ren)’s Name(s) and Date of Birth __________________________________ , ______________ __________________________________ , ______________ __________________________________ , ______________ Obligee Name -- OBLIGEE ___ If checked, you are 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 is based upon an order for support from KANSAS. You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice of the court. $______ per month in current support $______ per month in past due support Arrears 12 weeks or greater? ___yes ___no $______ per month medical support $______ per month maintenance $______ per month past due maintenance For a total of $________ per month to be forwarded to the payee below. $______ per weekly pay period. $______ per bi-weekly pay period (every two weeks). $______ per semi-monthly pay period (twice a month). $______ per monthly pay period. Federal Consumer Credit Protection Limit: The total withheld amount, including your fee, cannot exceed 50% of the employee’s/obligor’s aggregate disposable weekly earnings. Cost Recovery Fee: Employers may charge $5.00 per withholding, not to exceed $10.00 per month. REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifying information listed under #10 Additional Information. If the employee’s/obligor’s principal place of employment is Kansas, begin withholding no later than the first pay period occurring 14 days after the date of receipt of this Order. Send payment within 7 working days of the pay date/date of withholding. If the employee’s/obligor’s principal place of employment is not Kansas, 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). Make check payable to: KANSAS PAYMENT CENTER / WYCASE NUMBER. Send check to: KANSAS PAYMENT CENTER PO BOX 758599 TOPEKA KS 66675-8599 Authorized by Judge: ________________________________________________________ Div: _____________________ ____________________________________________________________ (signature of atty) American LegalNet, Inc. www.USCourtForms.com