INCOME WITHHOLDING FOR SUPPORT 1a 1b 1c 1e ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT TERMINATION of IWO Date: Child Support Enforcement (CSE) Agency Court Attorney Private Individual/Entity (Check One) 1d NOTE: If you receive this document from someone other than a State or Tribal Child Support Enforcement agency or a court, a copy of the underlying order that contains a provision authorizing income withholding must be attached. Or if under State law an attorney in that State, or if under Tribal law a Tribal legal representative, may issue an income withholding order, the attorney or Tribal legal representative must include a copy of the State or Tribal law authorizing the attorney or Tribal legal representative to issue an income withholding order. State/Tribe/Territory City/County/Dist./Tribe Private Individual/Entity 1f 1h 1j Case Identifier Order Identifier 1g 1i 2a Employer/Income Withholder's Name 2b Employer/Income Withholder's Address 2c RE: 3a Employee/Obligor's Name (Last, First, MI) 3b Employee/Obligor's Social Security Number (if known) 3c Custodial Party/Obligee's Name (Last, First, MI) Employer/Income Withholder's Federal EIN Use date stamp here Child's Name (Last, First, MI) 3d 3f 3h 3j 3l 3n Child's Birth Date 3e 3g 3i 3k 3m 3o ORDER INFORMATION: This document is based on the support or withholding order from 4 . You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ 5a Per 5b current child support $ 6a Per 6b past-due child support Arrears greater than 12 weeks? Yes No 6c $ 7a Per 7b current cash medical support $ 8a Per 8b past-due cash medical support $ 9a Per 9b current spousal support $ 10a Per 10b past-due spousal support $ 11a Per _ 11b other (must specify) 11c . for a total of $ 12a per 12b to be forwarded to the payee below. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ $ $ 13a 13b per weekly pay period per biweekly pay period (every two weeks) $ $ 13c 13d per semimonthly pay period (twice a month) per monthly pay period 14 ONE-TIME LUMP SUM PAYMENT Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is 15 , you must begin withholding no later than the first pay period that occurs 16 days after the date of 17 . Send payment within 18 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to _20___% of disposable income for all orders. If the employee/obligor's principal place of employment is not ____15____________________, see the ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS for limitations on withholding, applicable time requirements and any allowable employer's fees. Document Tracking Identifier 19 American LegalNet, Inc. www.FormsWorkFlow.com For EFT/EDI instructions, contact the EFT/EDI office at the website listed below. If paying by check, make check payable to: 21 . Include this Remittance Identifier with Payment: 22 Send check to: 23 FIPS code (If necessary): 24 25 26 27 Signature (if required by State or Tribal law): Print Name: Title of Issuing Official: 28 If checked, you are required to provide a copy of this form to the employee/obligor. If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy must be provided to the employee/obligor even if the box is not checked. ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS State-specific information may be viewed on the OCSE Employer Services website located at: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts.htm Priority: Withholding for support has priority over any other legal process under State law (or Tribal law if applicable) against the same income. If a Federal tax levy is in effect, please notify the contact person listed below. Combining Payments: You may combine withheld amounts from more than one employee/obligor's income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice against this employee/obligor and you are unable to fully honor all support Orders/Notices due to federal, State, or Tribal withholding limits, you must follow the State or Tribal law/procedure of the employee/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible, giving priority to current support before payment of any past-due support. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. Contact the agency or person listed below to determine if you are required to withhold or if you have any questions about lump sum payments. Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. 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 or Tribal law/procedure. The payor is liable for any amount up to the accumulated amount that should have been withheld and paid, and may be fined up to two hundred dollars ($200.00) for each failure to make the required deductions if the payor: a.) fails to withhold or pay the support in accordance with the provisions of the income assignment notice, or b.) fails to notify the person or agency designated to receive payments as required. 12 O.S. 1171.3 (B) (9) and 56 O.S. 240.2 (D) (10). 29 Anti-discrimination: You are subject to a