ACI INCOME WITHHOLDING INFORMATION CASE #: __________________________ PAYOR: _____________________________ S.S.# ______________________ PAYOR EMPLOYER INFO: __________________________________________ (Name) (Address) (Phone) (FEIN—Federal Employer Identification Number) Current child support plus child care amount: $________________ Court ordered payment on arrearage: (Guideline amount will be used if not court ordered) $________________ Total: $________________ Statutory fees will be added ---------------------------------------------------------------------------Please update information required by statute: Address of party: ___________________________________________________ Medical Insurance: __________________________________________________ Licenses: __________________________________________________________ Other: _____________________________________________________________ Employer information is needed for the Friend of the Court processing of an Income Withholding Notice. This information should be supplied when a support order is entered to avoid money being held in the system. Submitted by:_____________________________________________ Date:__________________________ American LegalNet, Inc. www.FormsWorkflow.com