1a ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination #1b Date: State/Tribe/Territory #1d City/Co./Dist./Reservation #1e Non-governmental entity or Individual #1f Case Number #1g #2a Employer’s/Withholder's Name #2b Employer’s/Withholder's Address #2c #2d Employer’s/Withholder's Federal EIN Number (if known) #1c RE: #3a Employee’s/Obligor’s Name (Last, First, MI) #3b Employee’s/Obligor’s Social Security Number #3c Employee’s/Obligor’s Case Identifier #3d Obligee’s Name (Last, First, MI) ORDER INFORMATION: This document is based on the support or withholding order from [State/Tribe] #4 You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice. Per # 5b current child support #13 $ # 5a Per # 6b past-due child support - Arrears greater than12 weeks? yes no $ # 6a Per # 7b current cash medical support $ # 7a Per # 8b past-due cash medical support $ # 8a Per # 9b spousal support $ # 9a Per #10b past-due spousal support $ #10a Per #11b other (specify) #11c $ #11a per #12b to be forwarded to the payee below. for a total of $ #12a 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 payment cycle, withhold one of the following amounts: $ # 14a per weekly pay period. $ # 14c per semimonthly pay period (twice a month). $ # 14b per biweekly pay period (every two weeks).$ # 14d per monthly pay period. . REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If , begin withholding no later than the first pay period the employee’s/obligor’s principal place of employment is #15 occurring #16 days after the date of #17 . Send payment within #18 working days of the pay date/date of withholding. The total withheld amount, including your fee, may not exceed #19 % of the employee's/obligor's aggregate disposable weekly earnings. , for limitations on If the employee’s/obligor’s principal place of employment is not #20 withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee’s/obligor’s principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). Make check payable to: Oklahoma Department of Human Services Send check to: Oklahoma Centralized Support Registry, P. O. Box 268809, Oklahoma City, OK 73126-8809 If remitting payment by EFT/EDI, call 405-522-2273 before first submission. Use this FIPS code: 4000000 : Bank account number: 010251577 . Bank routing number: 103000648 If this is a Notice of an Order to Withhold: If this is an Order/Notice to Withhold: 24a Print Name 25a Print Name 24b Title of Issuing Official Mandatory 25b Title (if appropriate) 25c Signature and Date 24c Signature and Date (if required by state or tribal law) 24d IV-D Agency Court 25d Attorney Individual Private Entity 24e Attorney with authority under state law to issue order/notice. NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and include a copy of the income withholding order unless, under a state’s law, an attorney in that state may issue an income withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the state law authorizing the attorney to issue an income withholding order/notice. IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. OMB 0970-0154 American LegalNet, Inc. www.USCourtForms.com ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS #26 If checked, you are required to provide a copy of this form to your employee/obligor. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee/obligor even if the box is not checked. 1. Priority: Withholding under this Order or Notice has priority over any other legal process under state law (or tribal law, if applicable) against the same income. If there are federal tax levies in effect, please notify the contact person listed below. (See 10 below.) 2. Combining Payments: You may combine withheld amounts from more than one employee’s/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. 3. 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 the 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 and forward the support payments. 4. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order or Notice against this employee/obligor and you are unable to honor all support Orders or Notices due to federal, state, or tribal withholding limits, you must follow the state or tribal law/procedure of the employee's/obligor's principal place of employment. You must honor all Orders or Notices to the greatest extent possible. (See 9 below.) 5. Termination Notification: You must promptly notify the Child Support Enforcement (IV-D) Agency and/or the contact person listed below when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this Order or Notice to the Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See 10 below.) THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: EMPLOYEE'S/OBLIGOR'S NAME: CASE IDENTIFIER: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: 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 Child Support Enforcement (IV-D) Agency. 7. Liability: If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below under 10. If you fail to withhold income as the Order or Notice directs, you are liable for both the accumulated amount you should have withheld from the employee’s/obligor's income and any other penalties set by state or tribal law/procedure. #27 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) 8. Anti-discrimination: You are subject to a fine determined under state or tribal 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. #28 Any payor who violates this section shall be liable to the obligor for all income, wages, and employment benefits lost by the obligor from the period of unlawful discipline, suspension, discharge, or refusal to promote until the time of reinstatement or promotion. 12 O.S. 1171.3 (B)(15) 56 O.S. 240.2 (D)(15) 9. Withholding Limits: For state orders, 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, statutory pension contributions, and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears greater than 12 weeks. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. Child(ren)’s Names and Additional Information: 10. #29 If you or your employee/obligor have any questions, contact #30a by Fax at #30c or by internet at #30b by telephone at #30d . American LegalNet, Inc. www.USCourtForms.com