ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT
NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT
Original
Amended
Termination
Date:
State/Tribe/Territory
City/Co./Dist./Reservation
Non-governmental entity or Individual
Case Number
RE:
Employer’s/Withholder's Name
Employee’s/Obligor’s Name (Last, First, MI)
Employer’s/Withholder's Address
Employee’s/Obligor’s Social Security Number
Employee’s/Obligor’s Case Identifier
Employer’s/Withholder's Federal EIN Number (if known)
Obligee’s Name (Last, First, MI)
ORDER INFORMATION: This document is based on the support or withholding order from
.
You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice.
$
Per
current child support
$
Per
past-due child support - Arrears greater than12 weeks?
yes
no
$
Per
current cash medical support
$
Per
past-due cash medical support
$
Per
spousal support
$
Per
past-due spousal support
$
Per
other (specify)
for a total of $
per
to be forwarded to the payee below.
You do not have to vary your pay cycle to be in compliance with the support order. 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.
REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If
the employee’s/obligor’s principal place of employment is
in the State of Alabama
, begin withholding no
later than the first pay period occurring
days after the date of
. Send payment within seven (7) working days of
the pay date/date of withholding. The total withheld amount, including your fee, may not exceed
% of the
employee's/obligor's aggregate disposable weekly earnings.
If the employee’s/obligor’s principal place of employment is not in the State of Alabama
, for limitations on
withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the
employee’s/obligor’s principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND
OTHER WITHHOLDERS).
Make check payable to: Alabama Child Support Payment Center (ACSPC)
Send check to: P. O. Box 244015, Montgomery, AL 36124-4015
.
If remitting payment by EFT/EDI, call 1-866-252-4453 before first submission. Use this FIPS code:
:
Bank routing number:
Bank account number:
.
If this is an Order/Notice to Withhold:
If this is a Notice of an Order to Withhold:
Print Name
Print Name
Title of Issuing Official
Title (if appropriate)
Signature and Date
Signature and Date
IV-D
Agency
Court
Attorney
Individual
Private Entity
Attorney with authority under state law to issue order/notice.
NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and
include a copy of the income withholding order unless, under a state’s law, an attorney in that state may issue an income
withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the state law
authorizing the attorney to issue an income withholding order/notice.
IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.
OMB 0970-0154