Manual

Employee/Obligor’s Name: ______3a________________________ Case Identifier: ___________1g__________________

Order Identifier: _______________ 1i____________ Employer’s Name: ____________________ 2a________________

INCOME WITHHOLDING FOR SUPPORT

1a  ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)  AMENDED IWO

1b  ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT

1c  TERMINATION of IWO Date: _______1d________

1e  Child Support Enforcement (CSE) Agency Court  Attorney  Private Individual/Entity (Check One)

NOTE:  If you receive this document from someone other than a State or Tribal Child Support Enforcement agency or a court, a copy of the underlying order that contains a provision authorizing income withholding must be attached.  Or if under State law an attorney in that State, or if under Tribal law a Tribal legal representative, may issue an income withholding order, the attorney or Tribal legal representative must include a copy of the State or Tribal law authorizing the attorney or Tribal legal representative to issue an income withholding order.

State/Tribe/Territory ______1f_______________________ Case Identifier ______1g ___________________________

City/County/Dist./Tribe _______1h ______________________ Order Identifier ______1i ___________________________

Private Individual/Entity______1j_________________________________________________________________________

_______2a _________________________________ RE: _______3a______________________________________

Employer/Income Withholder’s Name Employee/Obligor’s Name (Last, First, MI)

_______2b _________________________________ _______3b _____________________________________

Employer/Income Withholder’s Address Employee/Obligor’s Social Security Number (if known)

___________________________________________ _______3c ______________________________________

Custodial Party/Obligee’s Name (Last, First, MI)

___________________________________________

_______2c _________________________________

Employer/Income Withholder’s Federal EIN

Child Name (Last, First, MI) Child Birth Date

_______3d _______________________ _______3e ________

_______3f _______________________ _______3g ________

_______3h _______________________ _______3i _________

_______3j _______________________ _______3k ________

_______3l _______________________ _______3m ________

_______3n ______________________ _______3o ________

ORDER INFORMATION: This document is based on the support or withholding order from __4_____.

You are required by law to deduct these amounts from the employee/obligor’s income until further notice.

$__5a_________ Per ____5b________ current child support

$__6a_________ Per ____6b________ past-due child support - 6c Arrears greater than 12 weeks?  Yes No

$__7a_________ Per ____7b________ current cash medical support

$__8a_________ Per ____8b________ past-due cash medical support

$__9a_________ Per ____9b________ current spousal support

$__10a________ Per ____10b_______ past-due spousal support

$__11a________ Per ____11b_______ other (must specify) _____11c ________________________________.

for a total of $_______12a per __________________12b_____________ to be forwarded to the payee below.

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:

$___13a_____ per weekly pay period	$ ___13c_____ per semimonthly pay period (twice a month)
$ 13b_____ per biweekly pay period (every two weeks)	$ ___13d _____per monthly pay period

$___14_____ ONE-TIME 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 _______________15__________

________, you must begin withholding no later than the first pay period that occurs ___16__ days after the date of 17 . Send payment within ____18____ 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 __20__% of disposable income for all orders. If the employee/obligor’s principal place of employment is not ______________15___________________, see the ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS for limitations on withholding, applicable time requirements and any allowable employer’s fees.

For EFT/EDI instructions, contact the EFT/EDI office at the website listed below. If paying by check, make check payable to: _______________________21_________________________________. Include this Remittance Identifier with payment: ____________22 ___________. Send check to: _________23______________________________________

___________________________________________________________________________________________________

FIPS code (If necessary): _________24________

Signature (if required by State or Tribal law): ______25 ____________________________________________________

Print Name: ________________________________26____________________________________________________

Title of Issuing Official: _______________________27____________________________________________________

28  If checked, you are required to provide a copy of this form to the employee/obligor. If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy must be provided to the employee/obligor even if the box is not checked.

ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS

State-specific information may be viewed on the OCSE Employer Services website located at: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts.htm

Priority: Withholding for support has priority over any other legal process under State law (or Tribal law if applicable) against the same income. If a Federal tax levy is in effect, please notify the contact person listed below.

Combining Payments: You may combine withheld amounts from more than one employee/obligor’s income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor’s wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor’s principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments.

Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice against this employee/obligor and you are unable to fully honor all support Orders/Notices due to federal, State, or Tribal withholding limits, you must follow the State or Tribal law/procedure of the employee/obligor’s principal place of employment. You must honor all Orders/Notices to the greatest extent possible, giving priority to current support before payment of any past-due support.

Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. Contact the agency or person listed below to determine if you are required to withhold or if you have any questions about lump sum payments.

Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person 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 employee/obligor’s income and any other penalties set by State or Tribal law/procedure. (29)___________________________________________________________________________________________________________________________________________________________________________________________________

Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of a child support withholding. (30)_____________________________________________________________________________________

___________________________________________________________________________________________________

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. 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, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section.

Arrears greater than 12 weeks? If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage.

For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer 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, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits.

Additional Information: (31)

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

NOTIFICATION OF TERMINATION OF EMPLOYMENT: You must promptly notify the Child Support Enforcement agency and/or the person listed below by returning this form to the correspondence address if:

• This person has never worked for this employer.

• This person no longer works for this employer.

Please provide the following information for the terminated employee:

Termination date: ___________________ Last known phone number: ______________________________

Last known home address: ______________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Date final payment made to the State Disbursement Unit or Tribal CSE agency: ___________

Final payment amount: __________ New employer’s name: ____________________________________

_____________________________________________________________________________________________

New employer’s address: _____________________________________________________________________________________________

_____________________________________________________________________________________________

CONTACT INFORMATION

To employer: If the employer/income withholder has any questions, contact _____32______________________________

____________________ by phone at ______33___________, by fax at _________34________, by email or website at:

________________________________________35________________________________________________________.

Send termination notice and other correspondence to: __________________36__________________________________________________________

__________________________________________________________________________________________________.

To employee/obligor: If the employee/obligor has questions, contact ________37_______________________________

______________ by phone at ___________38_____, by fax_______________39___________, by email or website at

___________________________40_____________________________________________________________________.

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

OMB 0970-0154