NOTICE TO WITHHOLD INCOME IN THE DISTRICT COURT OF COUNTY, NEBRASKA COURT CASE NUMBER: Petitioner Vs. NOTICE TO WITHHOLD INCOME Respondent Re: Employee (Obligor): Employee's SSN: To: (Employer or Other Payor) PURSUANT TO NEB. REV. STAT. § 43-9718.02, YOU ARE HEREBY NOTIFIED OF THE FOLLOWING: 1) I, , the above named employee/obligor, have been ordered to have an amount withheld from my income to satisfy a child/spousal/medical support obligation. You are hereby directed to withhold $ per (or the equivalent based on your pay period) from my net disposable income or % of my net disposable income subject to CCPA limits (see (11)), whichever is less: For the purpose of income withholding, net disposable income is defined as that part of the employee's earnings remaining after the deductions for payment of federal and state income taxes, employment taxes, Social Security (FICA) deductions, mandatory retirement and federal or state income tax liens. 2) The above amount is based on my support obligations(s) of: Child Support $ per , and arrears of $ Spousal/Maintenance Support $ per , and arrears of $ $ per , and arrears of $ (If included in the child support order) Medical Support (That is reduced to a certain dollar amount) 3) Income withholding must be implemented no later than the first pay period that begins following the date of this notice. 4) If I as an employee take an advance draw on my income, each draw is to be considered a pay period for the purpose of income withholding. 5) You must forward the withheld amount to the Nebraska Child Support Payment Center at the address listed below within sever. (7) days of the date I am paid. Nebraska Child Support Payment Center P. 0. Box 82890 Lincoln, NE 68502-2890 6) I ( have ) ( have not ) been ordered to provide health insurance coverage for my dependent child(ren). American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS (7) Priority: Withholding under this order/notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order/notice have priority. (8) Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. (9) Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the child support payments. (10) Employee/Obligor with Multiple Support Withholding: If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (See #11 below) (11) Withholding Limits: You may not withhold more than the lessor 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; and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by: 1) 10% if the employee does not support a second family: and/or 2) 5% if arrears are more than 12 weeks old (see amounts on front) (12) Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. (13) Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and any other penalties set by State Law. Nebraska Employers: Pursuant to Neb. Rev. Stat. § 43-1724, if you fail to withhold income as the Order/Notice directs, you may be required to pay the certified amount. (14) Anti-discrimination: You are subject to a fine determined under State 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. Nebraska Employers: Pursuant to Neb. Rev. Stat. § 43-1725, you are subject to $500.00 fine and may be required to make full restitution to the aggrieved employee or payee, including reinstatement and back pay for (1) discrimination in hiring, (2) demotion of an employee or payee, (3) disciplinary action against an employee or payee, or (4) termination of an employee or payee. (15) Nebraska Employers: Per Nebraska law you are entitled to deduct a fee not to exceed two dollars and fifty cents ($2.50) in any calendar month to defray the costs of withholding. (16) Remitting Payment: When remitting payment, provide the paydate/date of withholding, name of county support order is entered in, court case number, and employee/obligor's name and social security number. Make it payable to: Nebraska Child Support Payment Center; Send to: Nebraska Child Support Payment Center, P. O. Box 82890, Lincoln, NE 68502-2890 If remitting by EFT/EDI, use this FIPS code: 31000; Bank routing code: 104000016; Bank account number: 22662057. (17) The income withholding requirement is binding and shall continue in full force and effect until 30 days after I cease employment or the source of income terminates. The withholding shall also terminate when I supply proof that the child, spousal/maintenance and medical support obligation terminates. The income withholding requirement may be modified or revoked by a court of competent jurisdiction. Notify the clerk of the district court if this wage assignment terminates because of termination of employment. Employee/Obligor's Signature Date Attorney's Signature / Bar I.D. Number Date Address: City: , State: , Zip: Instructions: 1) Complete the form; use a typewriter or print with a ballpoint pen 2) Sign notice 3) Make 2 copies after signing original 4) send or provide the original copy to your employer, send one of the copies to the Clerk of the District Court that your support order is entered in, and retain the second copy for your records. April, 2004 American LegalNet, Inc. www.FormsWorkflow.com