Order/notice To Withhold Income For Child Support Form

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ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

State of Illinois

Co./City/Dist. of ___________________________________

________ Original Notice

Date of Notice _____________________________________

________ Amended Notice

Court/Case Number ________________________________

________ Terminate Notice

RE: _____________________________________________________

___________________________________________________

)

Employer/Withholder’s Federal EIN Number

Employee/Obligor’s Name (Last, First, MI)

)

___________________________________________________

)

_____________________________________________________

)

Employer/Withholder’s Name

Employee/Obligor’s Social Security Number

)

___________________________________________________

)

_____________________________________________________

)

Employee/Obligor’s Case Identifier

______________________________________________

)

_____________________________________________________

Employer/Withholder’s Address

___________________________________________________

)

Custodial Parent’s Name (Last, First, MI)

)

Any subsequent employer

)

Child(ren)’s Name(s):

DOB

Child(ren)’s Name(s):

DOB

ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from _____________. By law,

you are required to deduct these amounts from the above-named employee’s/obligor’s income until ______________ even if the Notice is not issued by your

State. *See important information Employer Summary 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.____________________________________________________________________________

$_______________ per _________________ in current support

$_______________ per _________________ in past due support totaling $________Arrears 12 weeks or greater? [ ] yes [ ] no

$_______________ per _________________ in medical support

$_______________ per _________________ in 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 support payment cycle, use

the following to determine how much to withhold:

$__________ per weekly pay period.

$_________ per semimonthly pay period (twice a month).

$__________ per biweekly pay period (every two weeks).

$_________ per monthly pay period.

REMITTANCE INFORMATION: Follow the laws and procedures of the employee’s/obligor’s principal place of employment even if such laws and

procedures are different from this paragraph:

You must begin withholding no later than the first pay period occurring 14 working days after the date of this Notice. Send payment within seven (7) working

days of the paydate/date of withholding. You are entitled to deduce a fee of your actual cost not to exceed $4 monthly to defray the cost of withholding. The total

withheld amount, including your fee, cannot exceed ________% of the employee/obligor’s aggregate disposable weekly earnings. For the purpose of the

limitation on withholding, the following information is needed (see #9 on back):

When remitting payment provide the paydate/date of withholding and the case number,

County __________________________________.

If remitting by EFT/EDI, use this FIPS code*: ____________; Bank routing code*: ___________________; Bank account number:___________________.

Make check payable to: State Disbursement Unit

Send check to: State Disbursement Unit, P.O. Box 5400, Carol Stream, IL 60197-5400

SDU Phone Number (877) 225-7077

AUTHORIZED BY : ______________________________________________________________________________________________________________

Print Name: ______________________________________________________________________________________________________________________