ODHS 4048 (1/98) 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 3111.23(B), 3111.99, 3113.21(D), and 3113.99. 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 that 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 -- you may use the back of this form. 1. Of any change in the obligor's income source, and of 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. 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 of the availability of any other sources of income that can be the subject of any withholding or deduction requirement. WHEN THE TIME COMES FOR THE SUPPORT ORDER OR WITHHOLDING TO STOP Ohio Revised Code sections 3111.23(E) and 3113.21(G) 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. KEEP READING>>>>>> American LegalNet, Inc. www.USCourtForms.com ODHS 4048 (1/98) 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: FRANKLIN COUNTY CHILD SUPPORT ENFORCEMENT AGENCY, 373 South High Street, Columbus, Ohio 43215. A willful failure by either party to notify is contempt of court. Contempt may 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: Franklin County, CSEA DATE: SECTION A - OBLIGOR NOTIFICATION I have terminated my employment effective I will be employed as a and Payroll Address and Telephone Number) My new rate of pay will be $ Telephone number of employer or income source , 20 . [ ] I will receive unemployment benefits of $ per at (Name of New Employer per . I am scheduled to receive [ ] 12 [ ] 24 [ ] 26 [ ] 52 pay checks per year. I will become self-employed effective , 20 Said business shall have its business account at (Financial Institution) (City, State, Zip) in the name of . The nature of said business is (Address) Account Number I am drawing [ ] sick leave [ ] disability benefits in the amount of $ (Institution) (Address) per starting on (City, State, Zip) from My Workers' Compensation will [ ] commence [ ] terminate [ ] increase [ ] decrease effective per Claim No. . , 20 I have opened a new Financial Institution Account in the name of at (Name of Institution) (Address) Account Number (City, State, Zip) I am retiring effective (Source) (Address) per , 20 and will receive $ to $ . from I have acquired or expect to receive one or more of the following: Lump sum payment in excess of $500 as a result of: whose address is from Real Property Located at: Other property with a value in excess of $1,000 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 child: born, graduated from high school on ,20 married on , 20 [ ] no longer resides with me as of [ ] enlisted in the Armed Forces on 20 ; should stop because this , 20 , 20 any other reason that child support should not be paid: Please describe: as of Alimony should stop on , 20 , 20 Due to: [ ] Remarriage [ ] Death [ ] Full Time Employment [ ] Other, please describe OBLIGEE'S SIGNATURE American LegalNet, Inc. www.USCourtForms.com