ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT AND SPOUSAL SUPPORT (Ohio Revised Code 3121.03) Original Order/Notice Amended Order/Notice Terminate Order/Notice State: Ohio County: Hamilton Address: Hamilton County Domestic Relations Court 800 Broadway Street Case No:________________________________ File No:__________________________________ Cincinnati, OH 45202 RE:_________________________________________ Date of Issuance: _____________________________ Order Number:_______________________________ FIPS Code:__________________________________ Employee/Obligor’s Name (Last, First, MI) _____________________________________________ Employee/Obligor’s Social Security Number Employer/Withholder’s Name Federal EIN Number _________________________________________ Employer/Withholder’s Name Employee/Obligor’s Case Number Employer/Withholder’s Address ______________________________________________ Employee/Obligor’s Date of Birth Worker’s Compensation Claim Number ______________________________________________ Custodial Parent’s Name (Last, First, MI) Financial Institution Account Number Checking . Savings Child’s Name ___________________________________________ DOB:___________________ Child’s Name ___________________________________________ DOB:___________________ Child’s Name ___________________________________________ DOB:___________________ Child’s Name ___________________________________________ DOB:___________________ Child’s Name ___________________________________________ DOB:___________________ Child’s Name ___________________________________________ DOB:___________________ ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order from Hamilton County Domestic Relations Court. By law, you are required to deduct these amounts from the above-named employee’s/obligor’s income until further notice. If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee’s/obligor’s employment and to inform the child support enforcement agency of any lapses in coverage. $___________________ per MONTH in current support $___________________ per MONTH in past-due support Arreears 12 weeks or greater yes no $___________________ per MONTH in medical support $___________________ per MONTH Subtotal $___________________ per MONTH in other (specify) _________________________________________ for a Total of $_______________ per MONTH to be forwarded to 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 support payment cycle, 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 divide by 24. HCDHS 4047 (Rev.01/03) 4-Copies [ ] Obligee [ Page 1 ] Obligor [ ] Court [ ] CSEA American LegalNet, Inc. www.FormsWorkflow.com 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 payment immediately or within 7 business days of the paydate/date of withholding. Ohio Law: Financial institutions are required to send the amount deducted no later than fourteen working days following the date this notice was mailed and are required to continue the 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 payor may deduct a fee of $2.00 or 1% of amount to be withheld, whichever is greater (including an employer paying worker’s compensation). A financial institution may deduct a fee of $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 employee’s/obligor’s aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 for more information). When 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. Make check payable to: Send check to: Ohio Child Support Payment Central (CSPC) PO Box 182394 Columbus, OH 43218 Autherorized by: ( Ohio does not required hand written signature ) If you or your employee/obligor have any questions about the provisions of the notice or other communicatioon, contact: ____________________ of _________________________ County Child support Enforcement Agency by mail at _____________________________________, by telephone at _______________________ or FAX at __________________ or by internet at _____________________________________________________. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS 1. 2. 3. 4. If checked, you are required to provide a copy of this form to your employee. 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 Federal tax levies in effect please contact the requesting agency listed below. Combining Payments: You can combine withheld amounts from more than one employee/obligor’s income 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. 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. Employee/Obligor with Multiple Support Withholdings: 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 #9 below). Ohio Law: Payor shall prorate the amount due when two or more support orders are received for this obligor, which when combined exceed the limits of the Consumer Credit Protection Act. Multiply current support by a fraction with a numerator that represents the available amount of income and a denominator that represents the total amount designated for payment in the notices. Payors shall allocate to each notice an amount for current support equal to the 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 of income, or savings available for withholding and the denominator is the total amount designated in all of the notices as current support. If the total of the amounts designated in the notices as current support does not exceed the amount available for withholding under Consumer Credit Protection Act, the payor shall pay all of the amounts designated as current support in the notices and shall allocate to each notice an amount for past-due support equal to the amount designated in that notice as past-due support multiplied by a fraction in which the numerator is the amount of income remaining available for withholding after the payment of current support and the denominator is the total amount designated in all of the notices as past-due support. HCDHS 4047 (Rev.01/03) 4-Copies [ ] Obligee [ Page 2 ] Obligor [ ] Court [ ] CSEA American LegalNet, Inc. www.FormsWorkflow.com 5. Termination Notification: You must promptly notify the the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the requesting agency identified on page 2 of this form. Employee’s/Obligor’s Name: _____________________________________ SSN:______________________ Employee’s Case Identifier: ___________________________ Date of Separation: ______________________ Last Known Home Address:__________________________________________________________________ New Employer’s Address: ___________________________________________________________________ Ohio Law: Payors shall notify this county child support enforcement agency in writing within ten business days after the date of any situation that occurs in which the payor ceases to pay sufficient income to satisfy the ordered support, including termination of employment, layoff of the obligor from employment, any leave of absence of the obligor without pay, termination of workers’ compensation or benefits, or termination of any pension, annuity, allowance, or retirement benefit. Payors shall notify this county child support enforcement agency in writing of any benefits other than personal earnings due this obligor due to: termination of employment, worker’s compensation benefits, annuity, allowance, other benefit, income in account from which a deduction is made; the receipt of unemployment compensation, receipt of worker’s compensation, severance pay, sick leave, lump sum payment of retirement benefits or contributions, bonus, profit sharing, or distributions; the opening of any new account at this or another known institution. In addition to the above required information, include the new employee’s name, the social security number, date of birth and telephone number of the obligor. Financial institutions must promptly notify this county child support enforcement agency, in writing, within ten days after the date of any termination of the account from which the deduction is being made and notify the agency, in writing, of the opening of a new account at that financial institution, the account number of the new account, the name of any other known financial institutions in which the obligor has any accounts and the numbers of those accounts. The financial institution must include in all notices the obligor’s last known mailing address, last known residence address, and social security number. 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. Ohio Law: No later than the earlier of 45 days before the lump-sum payment is to be made or, of the date on which that determination is made, (if the obligor’s right to the payment is determined less than 45 days before it is to be made), the payor shall notify the county Child Support Enforcement Agency of any lump sum payments of any kind of $150 or more that is to be paid to the obligor, hold each lump sum payments of $150 or more for 30 days after the date on which it would otherwise be paid to the obligor, and on order of the court or CSEA, pay any specified amount of the lump sum to the Office of Child Support. 7. 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. Ohio Law: If the payor fails to comply with this notice, the county child support enforcement agency will bring an action requesting the court to issue an order requiring the compliance pursuant to Ohio Revised Code section 3121.37 or 3121.371. The payor may be found guilty of contempt of court. 8. 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 order/notice. 9. Withholding Limits: You may not withhold more than the lesser 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. HCDHS 4047 (Rev.01/03) 4-Copies [ ] Obligee [ Page 3 ] Obligor [ ] Court [ ] CSEA American LegalNet, Inc. www.FormsWorkflow.com According to the federal Consumer Credit Protection Act (CCPA), the amount withheld is not allowed to exceed: • • • • 50% of the noncustodial parent’s disposable earnings if he/she is supporting a spouse, dependent child or both, other than a party in the support order, or : 60% of the noncustodial parent’s disposable earnings if he/she is not supporting someone else. The Act also allows an additional 5% to be withheld above the maximum amount permitted if the noncustodial parent is twelve (12) or more weeks in arrearage. Ohio Law: Financial institutions and unemployment compensation benefits are not subject to the CCPA. No more than 50% of the noncustodial parent’s weekly unemployment benefit amount may be deducted. Note: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. This notice is final and enforceable by the court. Requesting Agency: Hamilton County Court of Domestic Relations, 800 Broadway, Cincinnati, Ohio 45202 If you or your employee/obligor have any questions, contact: ______________________________________________ (Name) ________________________________________________, at ___________________________________________. (Title) (Telephone Number) Ohio now offers a centralized source for making child support payments on behalf of your employees. You can make one payment to one central source. With Ohio Child Support Payment Central (CSPC) you can use CSPC-Direct (electronic data interchange), or CSPC-Through Your Financial Institution (electronic funds transfer). Call 1-888-965-2676 for your free Employer Kit. HCDHS 4047 (Rev.01/03) 4-Copies [ ] Obligee [ Page 4 ] Obligor [ ] Court [ ] CSEA American LegalNet, Inc. www.FormsWorkflow.com