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Income Withholding For Support (Non-IV-D b) LDSS-5037 - New York

Income Withholding For Support (Non-IV-D b) Form. This is a New York form and can be used in Matrimonial (Divorce) Supreme Court Statewide .
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LDSS-5037 (5/15) Part A Important Notice If you are issuing a Non-IV-D Income Withholding Order for child support or combined Important Notice child and spousal support, you must serve the completed LDSS-5037 as follows: Part A: serve only upon the NYS Child Support Processing Center (SDU), PO Box 15363, Albany, NY 12212-5363. Part B: serve upon all INCOME WITHHOLDING ORDER of the following: 1. employer/income withholder; 2. employee/obligor; 3. custodial party/obligee; and 4. NYS Child Support Processing Center (SDU) PO Box 15363, Albany, NY 12212-5363. Court Information Family Court: _________________ County Order ID (Index/Docket Number) Supreme Court: _________________ County Employee/Obligor Information Name (Last, First, Middle) Mailing Address Social Security Number - - Date of Birth (MM/DD/YYYY) / / Custodial Party/Obligee Information Name (Last, First, Middle) Mailing Address Social Security Number - - Date of Birth (MM/DD/YYYY) / / American LegalNet, Inc. www.FormsWorkFlow.com Page intentionally left blank. American LegalNet, Inc. www.FormsWorkFlow.com LDSS-5037 (5/15) 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 ID _______________________________________ _____________________________________________ 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 ID______________________________ 1 OMB 0970-0154 American LegalNet, Inc. www.FormsWorkFlow.com Employer's Name: __________________________ Employer FEIN: ________________________ Employee/Obligor's Name:___________________________ SSN:_________________________ New York Case Identifier: ____________________ Order Identifier: ________________________ 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 you cannot withhold the full amount of support for any or all orders for this employee/obligor, see Withholding Limits on page 3. If the obligor is a non-employee, obtain withholding limits from Supplemental Information on page 3. 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. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit (SDU)), contact the SDU at 888-208-4485 or see www.acf.hhs.gov/programs/css/employers/electronic-payments. Include the Remittance ID (until a New York Case Identifier is received), pay date, and write "Non-IV-D Services" on the payment. Remit payment to NYS Child Support Processing Center (SDU) at PO Box 15363, Albany, NY 12212-5363 Return to Sender [Completed by Employer/Income Withholder]. 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: __________________________________________________
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