Income Withholding For Support {JDF 1804}

District Court Denver Juvenile Court _________________________________________County, Colorado Court Address: In re the Marriage of: In re the Civil Union of: in re Parental Responsibilities concerning: ________________________________________________________ Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Case Number: Document Tracking Identifier: Phone Number: FAX Number: E-mail: Atty. Reg. #: Division Courtroom COURT USE ONLY INCOME WITHHOLDING FOR SUPPORT ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT TERMINATION of IWO 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 http://www.acf.hhs.gov/programs/cse/newhire/employer/publication/publication.htm#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) __________________ __________________ __________________ __________________ __________________ __________________ JDF 1804 Income Withholding For Support R2 14 © 2014 Colorado Judicial Department for use in the Courts of Colorado. This Colorado Form is Consistent with OMB 0970-0154 Expiration Date ­ 05/31/2014. The OMB expiration date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 $ ____________ Per _____________ past-due child support - Arrears greater than 12 weeks? Yes No $ ____________ Per _____________ current cash medical support $ ____________ Per _____________ past-due cash medical support $ ____________ Per _____________ current spousal/partner support $ ____________ Per _____________ past-due spousal/partner 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 http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm for the employee/obligor's principal place of employment. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit [SDU]), see http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm. Include the Remittance Identifier with the payment and if necessary this FIPS code:_____________________. Remit payment to at Family Support Registry P.O. Box 2171, Denver, CO 80201-2172 (SDU/Tribal Order Payee) (SDU/Tribal Payee Address) Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law):___________________________________ Print Name of Judge/Issuing Official:_____________________________________________________________ Title of Judge/Issuing Official:___________________________________________________________________ Date of Signature:____________________________________________________________________________ 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 of this IWO must be provided to the employee/obligor. If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm JDF 1804 Income Withhold