Fillable Income Withholding For Support (Page 3 of 3) in pdf

FL-195

Employer’s name:

Employer FEIN:

Employee/Obligor’s Name:

CSE Agency Case Identifier:

Order Identifier

Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer

Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor’s

principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making

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

Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the

disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if

the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The

combined support amount and the fee may not exceed the limit indicated in this section.

For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal

employers/income withholder who receive a State IWO, you may not withhold more than the lesser of the limit set by the law

of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section

303(d) of the CCPA (15 U.S.C. 1673 (b)).

Depending upon applicable State law or Tribal law, you may need to also consider the amounts paid for health care

premiums in determining disposable income and applying appropriate withholding limits.

Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then

the Employer should calculate the CCPA limit using the lower percentage.

Additional Information:

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, an employer 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 any questions, contact

(Issuer name)

by phone at

, by fax at

, by email or website at:

Send termination notice and other correspondence to:

(Issuer address).

To Employer/Obligor: If the employee/obligor has questions, contact

(Issuer name)

by phone at

, by fax at

, by email or website at:

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

For your protection and privacy, please press the Clear This Form

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Income Withholding For Support Page 3

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