JFS 4048 (02/2002) (Mahoning County Revision July 2006) ADDENDUM WITHHOLDING NOTICE TO PARTIES TO A SUPPORT ORDER Obligee Name: Court or Administrative Order Number: Social Security Number: Case Number: Obligor Name: Mahoning 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 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 of the availability of any other sources of income or assets that can be the subject of any withholding or deduction. 2. The nature of any new employment or income source and the name, business address and telephone number of the new employer or income source. 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/her commencement of employment, including self-employment, or of the availability of any other sources that can be the subject of any withholding or deduction requirement. 4, 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 4048 (02/2002) Keep Reading >>>>>>>>>>>>>>> JFS 4048 (02/2002) (Page 2 of 2) American LegalNet, Inc. www.FormsWorkflow.com 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: MAHONING COUNTY CHILD SUPPORT ENFORCEMENT AGENCY, 709 North Garland, P.O. Box 119, Youngstown, OH 44501-0600. 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 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 ___________, ____. per__________ [ ] I will receive unemployment benefits of __________ [] I will be employed as a __________________________________________________, at (Name of new employer and payroll address and telephone number) _______________________________________________________________________________________________ My new rate of pay will be $__________________ per ________. I am scheduled to receive [ ] 12 [ ] 24 [ ] 26 [ ] 52 pay checks per year. Telephone number of employer or income source __________________________________________________ [] I will become self-employed effective ___________________________, _____. 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 __________________________________________________________ [] from I am drawing [ ] sick leave [ ] disability benefits in the amount of $ _________________ per __________ starting on ____________ (Institution) ______________________________ (Address) ____________________________________ (City, State, Zip) ___________ [] My Worker’s Compensation will [ ] commence [ ] terminate [ ] increase [ ] decrease effective _______________________, 19_______ to $_______________________________per ___________________ Claim No. _______________________________________________ [] I have opened a new Financial of:___________________________________________________________. Account Number ___________________________ __________________________________________________ (Address)_________________________________ _______________________________________________________. Institution Account at (Name (City, in of name Institution) State, [] I am retiring effective ________________________________________, _____ $________________________________ per _____________ from (Source)_____________________________________________________. (Address) _________________________________________________________________________. [] the Zip) and will receive I have acquired or expect to receive one or more of the following: [] Lump sum payment in excess of of:______________________________________________________________________ from_________________________________ whose ___________________________________________________________. $150 as address a result is [] Real Property Located at:______________________________________________________________________________________ [] Other property with a value in excess of $1000 described as follows: _____________________________________________________ _________________________________________________________________________________________________________ _ [] etc. Other income or assets not otherwise included on this form such as lottery proceeds, inheritances, insurance settlements, tax refunds, described as _____________________________________________________________________________________________. follows: American LegalNet, Inc. www.FormsWorkflow.com OBLIGOR’S SIGNATURE __________________________________________________ SECTION B - OBLIGEE NOTIFICATION [] should Child Support for ____________________________________________________ born, ___________________, 19 _______; stop because this child: [] 19____ graduated from high school on ______________________, 19____ [ ] no longer resides with me as of _____________________, [] 19____ married on _____________________________________, 19____ [ ] enlisted in the Armed Forces on _____________________, [] any other reason that child support should not be ______________________________________________________ ________________________________________________________________________as 19_________ [] please paid: Please describe: of_______________________, Alimony should stop on _______________________, 19_____, Due to: [ ] Remarriage [ ] Death [ ] Full Time Employment [ ] Other, describe___________________________________________________________________________________________________ OBLIGEE’S SIGNATURE __________________________________________________ ACKNOWLEDGMENT I HEREBY ACKNOWLEDGE BEING PROVIDED A COPY OF THIS WITHHOLDING NOTICE. _______________________________________________________________ OBLIGOR __________________________________________________ OBLIGEE American LegalNet, Inc. www.FormsWorkflow.com