Appendix 3-2 ADDENDUM WITHHOLDING NOTICE TO PARTIES TO A SUPPORT ORDER Obligee Name Court or Administrative Order Number Social Security Number Case Number Obligor Name County Social Security Number Date WHY YOU WERE GIVEN THIS NOTICE This addendum notice is provided to the parties to the child/spousal support/withholding order in accordance with Ohio Revised Code sections 3121.036 and 3121.99 DUTIES OF SUPPORT OBLIGOR BEFORE SUPPORT WITHHOLDING STARTS As obligor, you are responsible for payment of support between the effective date of the support order and the date income withholding is initiated. Upon commencement of employment, the obligor may request the CSEA cancel any previous notices, if applicable, and to issue a notice requiring the withholding of an amount from his personal earnings for support. WHEN THE SUPPORT OBLIGOR MUST NOTIFY THE CHILD SUPPORT ENFORCEMENT AGENCY The notification must be in writing -- please use the back of this form if you want. 1. Of any change in the obligor’s income source, and if the availability of any other sources of income or assets that can be the subject of any withholding or deduction. 2. A description of the nature of any new employment or income source, the name and business address and telephone number of the employer. 3. Of any change in the status of the account from which the amount of support is being deducted or the opening of a new account with any financial institution, of his commencement of employment, including self employment, or the availablity of any other sources of income that can be the subject of any withholding or deduction requirement. 4. The nature of any new employment or income source and the name, business address, and telephone number of the new employer or income source. 5. Any other information reasonably required by the court or agency. WHEN THE TIME COMES FOR THE SUPPORT ORDER OR WITHHOLDING TO STOP Ohio Revised Code sections 3119.94 and 3119.87 require the obligee to notify the child support enforcement agency of any reason for which support and withholding should terminate. The obligor is permitted to make this notification. The reverse side of this form can be used to provide the required notices. Section A contains information that the obligor must provide. Section B contains information that the obligee must provide. JFS 04048 (Rev. 11/2001) American LegalNet, Inc. www.USCourtForms.com Appendix 3-2 Page 2 of 2 The Obligor shall check the appropriate boxes in Section A and fill in the needed information when any of these events occur. Section B may also be completed at Obligor's discretion. The custodial parent is obligated to complete Section B. Documents are to be mailed to: COUNTY CHILD SUPPORT ENFORCEMENT AGENCY,____________________________________________________________. A willful failure by either party to notify is contempt of court. Contempt can be accompanied by a fine of not more than fifty dollars for a first offense, not more than one hundred dollars for a second offense, and not more than five hundred dollars for each subsequent offense. NOTIFICATION TO: ______________________ CSEA DATE:___________________ SECTION A - OBLIGOR NOTIFICATION [ ] I have terminated my employment effective _________, 20__. [ ] I will receive unemployment benefits of ______ per _____ [ ] ,at (Name of new employer and Payroll Address and I will be employed as a telephone number) _________________________________________________________________________________________________________ Mynew rate of pay will be $_______________per______. I am scheduled to receive [ ] 12 [ ] 24 [ ] 26 [ ] 52 pay checks per year. [ ] I will become self-employed effective ______________,20__. The nature of said business is _________________________________. Said business shall have its business account at (Financial Institution)_________________________________________________________________, (Address)___________________________________________ (City, State, Zip)__________________________________________________ in the name of _____________________________________________. Account Number_____________________________________________________ [ ] I am drawing [ ] sick leave [ ] disability benefits in the amount of $________________per ______starting on ___________ from (Institution) __________________________________ (Address) ________________________________(City, State, Zip)___________ [] My Workers' Compensation will [ ] commence [ ] terminate [ ] increase [ ] decrease effective ____________, 20__ to $_____________________per ________________ Claim No. __________________________________ [ ] I have opened a new Financial Institution Account in the name of:______________________________________________________ Account Number _________________________at (Name of Institution) ____________________________________________________ (Address) _________________________________________ (City, State, Zip)________________________________________________. [ ] I am retiring effective ____________________________________________________, 20___ and will receive $______________ per _________ from (Source) _____________________________________________________. (Address)_____________________________________________________. [ ] I have acquired or expect to receive one or more of the following: [ ] Lump sum payment in excess of $150 as a result of:___________________________________________________________________________ from_________________________________________ whose address is _____________________________________________________. [ ] Real Property Located at: ____________________________________________________________________________________________________________ [ ] Other property with a value in excess of $1000 described as follows:_______________________________________________________________________________________________________________________ _______________________________________________________________________ [] Other income or assets not otherwise included on this form such as lottery proceeds, inheritances, insurance settlements, tax refunds, etc. described as follows:________________________________________________________________________________. OBLIGOR'S SIGNATURE__________________________________________________ SECTION B - OBLIGEE NOTIFICATION [ ] Child Support for ______________________________________ born, _______________________, 20____; should stop because this child: [ ] graduated from high school on ______________________, 20____ [ ] no longer resides with me as of _____________, 20___ [ ] married on _________________________________________, 20___ [ ] enlisted in the Armed Forces on _____________, 20___ [ ] any other reason that child support should not be paid: Please describe: ______________________________________________________________________________________________________________ as of________________________, 20___ [ ] Alimony should stop on_______________, 20___, Due to: [ ] Remarriage [ ] Death [ ] Full Time Employment [ ] Other, please describe_______________________________________________________________________________________________________________________ _________________________________________________________________________________________________ OBLIGEE'S SIGNATURE ________________________________________________ American LegalNet, Inc. www.USCourtForms.com