Order Notice To Withhold Income For Child Support (Page 2 of 2) in pdf

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

If checked, you are re quired to provid e a co py of this form to yo ur employee. If your emplo yee wo rks in a state that is

different from the state that issued this order, a copy must be provided to your employee even if the box is not checked.

W e appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned

businesses located on a reservation that choose to withhold in accordance with this notice.

Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same

income. Federal tax levies in effect before receipt of this order ha ve priority. If there are Fede ral tax levies in effect, please

contact the State Child Support Enforcement Agency or party listed in number 12 below.

Combining Pay ments: You can co mbine withheld amounts from more than one employee’s/obligor's income in a single payment

to eac h agen cy/party reque sting withho lding. Y ou must, however, separately identify the portion of the single payment that is

attributable to each employee/obligor.

Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The

paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comp ly with the

law of the state of employee's/obligor's principal place o f employment with respect to the time periods within which you must

impleme nt the withholding ord er and forward the supp ort payments.

Emp loyee/O bligor w ith M ultiple Support W ithholdings: If there is more than one Order/Notice to Withhold Income for

Child Support against this emplo yee/ob ligor and you are unable to hono r all supp ort O rder/Notices due to Fe deral or State

withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor

all Ord er/Notices to the grea test extent possib le. (See #10 below.)

Termination Notification: You must prom ptly notify the Child Suppo rt Enforcement Agency or payee when the

emp loyee/o bligor no longer works fo r you. P lease p rovid e the informatio n requested and return a com plete copy o f this

order/notice to the Child Support Enforcement Agency or payee.

EMPLOYEE'S/OBLIGOR'S NAME: __________ __________ __________ _____ CASE IDENTIFIER: __________________

DATE OF SEPARATION FROM EMPLOYMENT:

LAST KNOWN HOME ADDRESS:

NEW EMPLOYER/ADDRESS:

Lump S um Pa yments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or

severance pay. If you have a ny questions ab out lum p sum paym ents, contact the perso n or authority below .

Liability: If you have any d oubts about the validity of the O rder/Notice, contact the agenc y or pe rson listed below. If you fail to

withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the

emp loyee’s/o bligor's income and any other penalties set b y State law .

Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from

employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support

withholding.

10.

W ithholding Limits: Yo u may not withho ld mo re than the lesser of: 1) the amo unts allowed by the Federal Co nsumer Credit

Protection Act (15 U.S.C. § 1673(b)); or 2) the amounts allowed by the State of the employee's/obligor's principal place of

employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE ). ADWE is the net income left after

making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions, and

Medica re taxes.

Additional Information:

11.

Submitted by

12.

If you or your emplo yee/ob ligor have any q uestions, contact:

______________________________

by telep hone at

or by F AX at

or by Internet

________________________________________________

OMB: 0970-0154

IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.

Order Notice To Withhold Income For Child Support Page 2

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