STATE OF MAINE SUPERIOR COURT __________________________, ss Docket No.___________________ DISTRICT COURT Location___________________________ Docket No._________________________ Plaintiff v. IMMEDIATE INCOME WITHHOLDING ORDER Defendant Name of Obligor: Obligor's Support Enforcement Member Number (if known): Name of Obligee: Weekly Withholding Amount to Satisfy Current Support Obligation: This Immediate Income Withholding Order, issued pursuant to 19-A M.R.S.A. § 2651 et seq, is incorporated in the Divorce Judgment or Order of this court of this date. This Order may be used to collect current support and past-due support. To the payor of income to the obligor from any source: It is ORDERED that: 1. Beginning on the next date the obligor is usually paid after you receive a copy of this Order, you shall withhold each week from any amounts due the obligor: A. The above stated weekly withholding amount to satisfy the current support obligation; B. An additional amount to be applied toward any past-due support owed by the obligor, if a notice of such an additional amount is served on you with a copy of this withholding order; and C. A fee of $2.00 per week in addition to the amount withheld for child support. The fee shall be sent to the Department of Health & Human Services. 2. Within 7 days after the next usual date the obligor receives payment and each payment date thereafter, you shall send the amount of any withholding, along with the $2.00 fee and the obligor's support enforcement member number, if known, to: Department of Health & Human Services, IV-D Cashier, Box 1098, Augusta, ME 04332. Notice is hereby given that the amount of the withholding shall not exceed the limitations imposed by the United States Code, Title 15, § 1673(b). 3. Within 15 days after such time as you are no longer paying income from any source to the obligor, you shall notify the Department of Health & Human Services in writing of such termination, giving the obligor's name, the obligor's last known address, the obligor's Social Security number, the obligor's support enforcement member number, the date of termination, and, if known, the identity of any new payor of income to the obligor. This Order shall remain in effect until (1) terminated by order of the court; (2) you are released in writing from its terms by the Department of Health & Human Services; or (3) if this order was implemented by the obligee as a private withholding action, you are released in writing from its terms by the obligee. Knowing failure of a payor to withhold or send support payments required by this Order or to notify in the event of termination of the relationship is a civil violation and may subject the payor to civil liability, including costs, attorney's fees, and a $100 civil penalty for each such knowing failure. A payor who discharges an obligor from employment or refuses to employ an obligor or who takes disciplinary action against an obligor employed by the payor or who otherwise discriminates against the obligor because of the existence of an income withholding order or the obligations imposed upon the payor by this Order is subject to a civil penalty not to exceed $5,000 and is also subject to a civil action by the obligor for compensatory and punitive damages, together with attorney's fees and court costs. It is further ORDERED that this Order be incorporated in the docket by reference pursuant to M.R.Civ.P 79(a). Date: FM-133, Rev. 09/05 Judge / Justice / Magistrate American LegalNet, Inc. www.USCourtForms.com