Form Omb 0970-0154 - Income Withholding Order For Support Page 4
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4Employer's Name:
Employer FEIN:
Employee/Obligor's Name:
SSN:
CSE Agency Case Identifier:
Order Identifier:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for
you or you are no longer withholding income for this employee/obligor, you must promptly notify the CSE agency and/or
the sender by returning this form to the address listed in the contact information below:
This person has never worked for this employer nor received periodic income.
This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date:
Last known phone number:
Last known address:
Final payment date to SDU/tribal payee:
Final payment amount:
New employer's name:
New employer's address:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have questions, contact
(issuer name)
by phone:
, by fax:
, by e-mail or website:
.
Send termination/income status notice and other correspondence to:
(issuer address).
Office of the Attorney General, Child Support Division, Central File Maintenance, PO Box 12048, Austin TX 78711-2048
To Employee/Obligor: If the employee/obligor has questions, contact
(issuer name)
by phone:
, by fax:
, by e-mail or website:
.
The Paperwork Reduction Act of 1995
This information collection and associated responses are conducted in accordance with 45 CFR 303.100 of the Child Support Enforcement
Program. This form is designed to provide uniformity and standardization. Public reporting burden for this collection of information is
estimated to average 5 minutes per response for Non-IV-D CPs; 2 minutes per response for employers; 3 seconds for e-IWO employers,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number.
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