In The District Court Of Douglas County Nebraska Notice To Withhold Income
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2IN THE DISTRICT COURT OF DOUGLAS COUNTY, NEBRASKA
CASE NO. __________________________
______________________________________________
)
Petitioner/Plaintiff,
)
)
NOTICE TO
vs.
)
WITHHOLD INCOME
)
(Voluntary)
______________________________________________
)
Respondent/Defendant.
)
Date:
RE: Employee (Obligor) ___________________________________
TO: _________________________________________
Employer/Other Obligor
Employer Address
(Employee/Obligor Address)
Employee Soc. Sec. No.: ___________________________________
Employer Telephone Number
PURSUANT TO NEBRASKA REVISED STATUTE, SEC, 43-1718.02, YOU ARE HEREBY NOTIFIED OF THE FOLLOWING:
(1)
The above-named employee is ordered to have an amount withheld from his/her income to satisfy a child/spousal/medical
support obligation. You are hereby directed to withhold $ __________________ per _________________ (or the equivalent
based on your pay period-from the net disposable income of your employee, or ________________ % of the employee's net
disposable income subject to CCPA limits (See (9)), whichever is less.
For the purpose of income withholding, "net disposable income" is defined as that part of the employee's earnings remaining
after the deductions for payment of federal and state income taxes, employment taxes, FICA deductions, mandatory
retirement and federal or state income tax liens.
(2)
The above amount is based on the employee's ordered support obligation of-,
Child/Day Care $ ______________________ per ________________ and arrears of $ ______________ as of __________
Spousal Support
$ ______________ per ________________ and arrears of $ ______________ as of __________
(Spousal support only – no child support order entered)
Court Order
Medical (circle one) $ _____________________________ per _______________
(3)
Income withholding must be implemented NO LATER THAN the first pay period occurring after fourteen (14) days following
the date of this notice.
(4)
If the withholding is for an employee and he/she takes an advance draw on his/her income, each draw is to be considered a
pay period for the purpose of income withholding.
(5)
You MUST forward the withheld amounts to the Clerk of the Douglas County District Court at the address listed below
WITHIN TEN (10) DAYS of the date the employee is paid (whether on regular payday or earlier, whichever occurs first).
SEND WITHHELD AMOUNTS TO:
Clerk of the District Court - Douglas County Courthouse
Hall of Justice - Room #300
Omaha, ,NE 68183
REMITTANCE MUST INCLUDE: EMPLOYEE'S NAME, Social Security Number, DOCKET AND PAGE NUMBER and the
date on which the amount was withheld from the employee's wages or other income (i.e. the employee's payday).
(6)
The employee (has _____/has not _____ been ordered to provide health insurance coverage for his/her dependent
children.
(7)
You may retain an additional amount from the employee's net disposable income not to exceed $2.50 per month to offset
the administrative costs associated with the Notice to Withhold Income.
(8)
You shall pay the employee on his/her regularly scheduled payday the amount earned minus the support amount indicated
on this Notice. The sum total of the amount to be withheld, including the administrative fee, is limited to the amount specified
in the Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)). The limits provided in the CCPA are 50% of net
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