Income Withholding For Support Form
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3INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION of IWO
Date: _______________________________
Child Support Enforcement (IV-D) Agency
Court
Attorney
Private Individual/Entity
(Check One)
NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO
instructions
-forms). If you receive this document
from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory
INDIANA
Remittance Identifier/
City/County/Dist./Tribe
______________________________
Case Number:
___________________________________
Private Individual/Entity
______________________________
Cause Number:
___________________________________
RE: ____________________________________________________
___________________________________________________
Employee/Obligor’s Name (Last, First, Middle)
Employer/Income Withholder’s Name
____________________________________________________
___________________________________________________
Employee/Obligor’s Social Security Number
Employer/Income Withholder’s Address
____________________________________________________
___________________________________________________
Custodial Party/Obligee’s Name (Last, First, Middle)
___________________________________________________
Employer/Income Withholder’s FEIN __________________
Child(ren)’s Name(s) (Last, First, Middle)
Child(ren)’s Birth Date(s)
_________________________________
_________________
_________________________________
_________________
_________________________________
_________________
_________________________________
_________________
_________________________________
_________________
_________________________________
_________________
ORDER INFORMATION: This document is based on the support or withholding order from Indiana. You are required by law to deduct
these amounts from the employee/obligor’s income until further notice.
$ _________
Per _________________________
current child support
$ _________
Per _________________________
past-due child support - Arrears greater than 12 wks?
Yes
No
$ _________
Per _________________________
current cash medical support
$ _________
Per _________________________
past-due cash medical support
$ _________
Per _________________________
current spousal support
$ _________
Per _________________________
past-due spousal support
$ _________
Per _________________________
other (specify) ________________________________________________
For a Total Amount to Withhold of $
per
.
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:
$
____________
per weekly pay period.
$
____________
per semimonthly pay period (twice a month).
$
____________
per biweekly pay period (every two weeks)
$
____________
per monthly pay period.
ONE ____________
$
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 Indiana, you must begin withholding no later
than the first pay period that occurs 14 days after the date this order is received. Send payment the same day as the pay date/date of
withholding. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to ___% of
disposable income for all orders. If the employee/obligor’s principal place of employment is not Indiana, obtain withholding limitations,
time requirements, and any allowable employer fees at
for the employee/obligor’s principal place of
employment.
Document Tracking Identifier ______________________________________
OMB 0970-0154
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