APPENDIX 3-1 ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD AND SPOUSAL SUPPORT (Ohio Revised Code 3121.037) State OHIO Original Order/Notice County Amended Order/NoticeDate of Issuance Terminate Order/NoticeOrder Number FIPS Code RE: Employer/Withholders Federal EIN Number Employee/Obligors Name (Last, First, M I) Employer/Withholders Name Employee/Obligors Social Security Number Employer/Withholders Address Employee/Obligors Case Number Workers Compensation Claim Number Employee/Obligors Date of Birth Financial Institution Account Number Custodial Parents Name (Last, First, MI) Checking Savings Child(ren)s Name(s): DOB Child(ren)s Name(s): DOBORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an o rder from . By law, you are requiredto deduct these amounts from the above-named employees/obligors income until further notice q If checked, you are required to enroll the child(ren) identified abov e in any health insurance coverage available through the employees/o bligorsemployment and to inform the child support enforcement agency of any lapses in cove rage. $ per in current support $ per in past-due supportArrears 12 weeks or greater? q yes q no $ per in medical support $ per Subtotal (for Ohio Bureau of Employment Services Withholding)$ per in other (specify) for a Total of $ per to be forwarded to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered suppor t paymentcycle, use the following to determine how much to withhold: 1. If pay cycle is weekly, multiply the monthly amount by 12 and divide by 52. 2. If pay cycle is every other week, multiply monthly amount by 12 and divide by 26. 3. If pay cycle is twice monthly, multiply monthly amount by 12 and div ide by 24. REMITTANCE INFORMATION: An employer must begin withholding no later than the first pay period occurring 14 business days after the date of this Order/Notice. Send paymentimmediately or within 7 business days of the paydate/date of withholding. Ohio Law: Financial institutions are required to send theamount deducted no later than fourteen business days following the date this notice was mailed and are required to continuethe deduction thereafter IMMEDIATELY, but not later than seven (7) business days after the payment or deduction is made. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of the employee for the allowable amount.Ohio Law: A withholder may deduct a fee of $2.00 or 1% of amount to be withheld, w hichever is greater (including an employerpaying workers compensation). A financial institution may deduct a fee o f $5.00 or a fee not to exceed the lowest rate, if any,charged for a similar debt transaction, whichever is less of the amount specified to be withheld. The total withheld amount, including your fee, cannot exceed 65% of the employees/obligors aggregate disposable weekly earnings . For the purposeof the limitation on withholding, the following information is needed ( see #9 on back for more information). JFS 04047 (Rev. 11/2001) American LegalNet, Inc. www.USCourtForms.com>>>> 2 Appendix 3-1 Page 2 of 4When remitting payment, provide the Paydate/Date of Withholding, Obligor Name, Social Security Number, Case Number and the Order number.When remitting for more than one obligor, include the amount of payment for each person. If you choose to remit by EFT/EDI, contact Ohio Child Support Payment C entral to obtain bank file format. (See Page 4 of this document)Make it payable to: Ohio Child Support Payment Central (CSPC) Send check to: PO Box 182394 Columbus, OH 43218 Authorized by: (Ohio does not require a hand written signature) If you or your employee/obligor have questions about the provisions of t he notice or other communication, contact:_______________________of ____________________County Child Suppo rt Enforcement Agency by mail at _________________________,_______________________________, by telephone at __________________________ or by FAX at ____________________or by intern et at _________________________________________________. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS q If checked you are required to provide a copy of this form to your emplo yee. 1. 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 have priority. If there are Fede ral tax levies in effect please contact the requesting agency listed bel ow.2. Combining Payments: You can combine withheld amounts from more than one employee/obligors i ncome in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.3.* 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 employees wages. You must comply with the law of the state of employees/obligors principal place of employment with respect to the time periods within which you must implement the withholding order and forward the child support payments. 4.* Employee/Obligor with Multiple Support Withholdings: If there is more th an 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, y ou must follow the law of the state of employees/obligors principal place of employment . You must honor all Order/Notices to the greatest extent possible. ( See #9 below) Ohio Law: Payors shall prorate the amount due when two or more support orders are received for this obligo r, which when combined exceed the limits of the Consumer Credit Protection Act. Multiply curr ent support by a fraction with a numerator that represents the available amount of income and a denominator that repres ents the total amount designated for payment in the notices. Payors shall allocate to each notice an amount for current support equal to th e amount designated in that notice as current support multiplied by a fraction in which the numerator is the amount of personal earnings, payments, pensions, annuities, allowances, benefits, other sources