FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.04, continued) ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT [] ORIGINAL [] AMENDED [] TERMINATION Date: State/Tribe/Territory City/Co./Dist./Reservation Non-governmental entity or Individual Case Number / Employer’s/Withholder’s Name RE: Employee’s/Obligor’s Name (Last, First, MI) Employer’s/Withholder’s Address Employee’s/Obligor’s Social Security Number Employee’s/Obligor’s Case Identifier Employer’s/Withholder’s Federal EIN Number (if known) Obligee’s Name (Last, First, MI) ORDER INFORMATION: This document is based on the support or withholding order from . You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice. $ Per current child support Past-due child support – Arrears greater than 12 weeks? yes no $ Per $ Per current cash medical support $ Per past-due cash medical support $ Per spousal support $ Per past-due spousal support $ Per other (specify) for a total of $ per ____ to be forwarded to the 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 payment cycle, withhold one of the following amounts: $ per weekly pay period. $ per semimonthly pay period (twice a month). $ per biweekly pay period (every two weeks). $ per monthly pay period. REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the employee’s/obligor’s principal place of employment is Tennessee, begin withholding no later than the first pay period occurring 14 working days after the date of _______. Send payment within 7 working days of the pay date/date of withholding. The total withheld amount, including your fee, may not exceed 50% of the employee’s/obligor’s aggregate disposable weekly earnings. If the employee’s/obligor’s principal place of employment is not Tennessee, for limitations on 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). Send check to: Make check payable to : ____________________ If remitting payment by EFT/EDI, call ____________ before first submission. Bank routing number: Bank account number: . Use this FIPS code: _____________________ ______________________ _____________________ If this is a Notice of an Order to Withhold: Print Name _____________________________________ Title (if appropriate) ______________________________ Signature ______________________________________ Date Private Entity If this is an Order/Notice to Withhold: Print Name _______________________________________ Title of Issuing Official Signature ________________________________________ Date IV-D Agency Court Attorney Individual 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 October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.04, continued) ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS 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 the 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: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: CASE IDENTIFIER: 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. 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. 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: Tennessee Employers/Payers of Income should refer to the Department’s Rule 1240-2-2-.05, available on the Internet at http://www.state.tn.us/sos/rules/1240/1240-02/1240-02-02.pdf, for state specific information about the priority and proration of payments if multiple Orders/Notices are received for one employee. 10. If you or your employee/obligor have any questions, contact: by Fax at or by Internet at October, 2005 (Revised) by telephone at @ 2 American LegalNet, Inc. www.USCourtForms.com