Income Withholding For Support
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FL-195
finished.
INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION of IWO
Date:
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 - forms).
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 Identifier (include w/payment)
City/County/Dist./Tribe
Order Identifier
Private Individual/Entity
CSE Agency Case Identifier
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.
REMITTANCE INFORMATION: If the employee/obligor’s principal place of employment is
(State/Tribe),
you must begin withholding no later than the first pay period that occurs
days after the date of
. Send
payment within
working days of the pay date. If you cannot withhold the full amount of support for any or all orders
for this employee/obligor, withhold up to
% of disposable income for all orders. If the employee/obligor’s principal
place of employment is not
(State/Tribe), obtain withholding limitations, time requirements, and any
allowable employer fees at for the
employee/obligor’s principal place of employment.
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