Form Omb 0970-0154 - Income Withholding Order For Support
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4INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
Date:
TERMINATION OF IWO
Child Support Enforcement (CSE) 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 ). 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
Remittance ID (include w/payment)
TEXAS
City/County/Dist./Tribe
Order ID
Private Individual/Entity
CSE Agency Case ID
RE:
Employer/Income Withholder's Name
Employee/Obligor's Name (Last, First, Middle)
Employer/Income Withholder's Address
Employee/Obligor's Social Security Number
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
(State/Tribe). You are required by law to deduct these amounts from the employee/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
current spousal support
$
Per
past-due spousal support
$
Per
other (must 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
$
Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
Document Tracking ID
OMB 0970-0154
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