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Income Withholding For Support (Non-IV-D a - Spousal Support Only) LDSS-5038 - New York

Income Withholding For Support (Non-IV-D a - Spousal Support Only) Form. This is a New York form and can be used in Matrimonial (Divorce) Supreme Court Statewide .
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LDSS-5038 (4/14) Part A Important Notice If you are issuing a Spousal Support Only Income Withholding Order, you must serve the completed LDSS-5038 as follows: Part A: serve only upon the employer/income withholder. INCOME WITHHOLDING ORDER Part B: serve upon all of the following: 1. employer/income withholder; 2. employee/obligor; and 3. obligee. Court Information Family Court: _________________ County Order ID (Index/Docket Number) Supreme Court: _________________ County Employee/Obligor Information Name (Last, First, Middle) Social Security Number Date of Birth (MM/DD/YYYY) / / Obligee Information Name (Last, First, Middle) Mailing Address American LegalNet, Inc. www.FormsWorkFlow.com Page intentionally left blank. American LegalNet, Inc. www.FormsWorkFlow.com LDSS-5038 NOTE- Grayed out areas of this form are NOT applicable to spousal support only cases INCOME WITHHOLDING FOR SUPPORT Part B ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO Date: _____________________ Court Attorney Private Individual/Entity (Check One) Child Support Enforcement (CSE) Agency 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 www.acf.hhs.gov/programs/css/resource/income-withholding-for-support-instructions). 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 ID (include w/payment) _________________________ City/County/Dist./Tribe _______________________ Order ID _______________________________________________ Private Individual/Entity ______________________ New York Case Identifier __________________________________ _____________________________________________ Employer/Income Withholder's Name _____________________________________________ Employer/Income Withholder's Address _____________________________________________ _____________________________________________ Employer/Income Withholder's FEIN _______________ Child(ren)'s Name(s) (Last, First, Middle) ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Child(ren)'s Birth Date(s) ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ RE: _____________________________________________ Employee/Obligor's Name (Last, First, Middle) _____________________________________________ Employee/Obligor's Social Security Number _____________________________________________ Custodial Party/Obligee's Name (Last, First, Middle) ORDER INFORMATION: This document is based on the support or withholding order from New York State. 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 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. Document Tracking Identifier_____________________________________ 1 OMB 0970-0154 American LegalNet, Inc. www.FormsWorkFlow.com Employer's Name: __________________________ Employee/Obligor's Name: __________________ New York Case Identifier: ____________________ Employer FEIN: ________________________ SSN: _________________________________ Order ID: _____________________________ REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is New York State, you must begin withholding no later than the first pay period that occurs 14 days after the date of service of this notice. Send payment within 7 working days of the pay date. If the employee/obligor's principal place of employment is not New York State, obtain withholding limitations, time requirements, and any allowable employer fees at www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-information for the employee/obligor's principal place of employment. Include the Remittance ID, pay date and employee/obligor's name on the payment. Make payments payable in the name of the obligee identified on PART A. Remit payment to obligee's address identified on PART A. Payment must be directed to an SDU in accordance with 42 USC ยง666(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: www.acf.hhs.gov/programs/css/resource/state-income-withholding-contact
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