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 Case No:________________________________ File No:__________________________________ RE:_________________________________________ Employee/Obligor's Name (Last, First, MI) _____________________________________________ Employee/Obligor's Social Security Number Employer/Withholder's Federal EIN Number State: Ohio County: Hamilton Address: Hamilton County Domestic Relations Court 800 Broadway Street Cincinnati, OH 45202 Date of Issuance: _____________________________ Order Number:_______________________________ FIPS Code:__________________________________ _________________________________________ Employer/Withholder's Name Employer/Withholder's Address Employee/Obligor's SETS Number ______________________________________________ Employee/Obligor's Date of Birth Worker's Compensation Claim Number Financial Institution Account Number Checking . Savings ______________________________________________ Custodial Parent's Name (Last, First, MI) 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 Arrears 12 weeks or greater yes no $___________________ $___________________ per MONTH in medical support $___________________ per MONTH in Cash Medical $___________________ 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 (Revised 03/16/2016) 4-Copies [ ] Obligee [ ] Obligor Page 1 [ ] 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 C