Connecticut > Statewide > Family
Order To Withhold Income For Child Support JD-FM-1 - Connecticut
| Order To Withhold Income For Child Support Form. This is a Connecticut form and can be used in Family Statewide . |
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ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination State of Connecticut Co./City/Dist. of Tribunal/Case Number Employers/Withholders Name Employers/Withholders Address Child(ren)s Name(s): DOB Employers/Withholders Federal EIN Number (if known) RE: Employees/Obligors Name (Last, First, MI) Employees/Obligors Social Security Number Employees/Obligors Case Identifier Obligees Name (Last, First, MI) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available to the employee/obligor through his/her employment. ORDER INFORMATION - This Order is based on the support order from .You are required by law to deduct these amounts from the employees/obligors income until further notice. $ Per current child support $ Per past-due child support - Arrears 12 weeks or greater? yes no $ Per current medical support $ Per past-due medical support $ Per spousal support $ Per other (specify) for a total of $ per to be forwarded to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. 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. REMITTANCE INFORMATION - When remitting payment, provide the pay date/date of withholding and the case identifier. If the employees/obligors principal place of employment is Connecticut, begin withholding no later than the first pay period occurring 14 days after the date of service or, in the case of a payer of income other than an employer, begin withholding no later than the date of periodic payment occurring 14 days after the date of service. Send payment within 7 working days of the pay date/date of withholding. The total withheld amount, including your fee, cannot exceed % of the employees/obligors aggregate disposable weekly earnings. If the employees/obligors principal place of employment is not Connecticut, for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employees/obligors principal place of employment (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting payment by EFT/EDI, call 1-888-233-7223 (option 3) before first submission. Use this FIPS code: 0900003 Bank routing code (EFT Payment): ABA 053110400 Bank account number (EFT Payment): 2000013946793 Make check payable to: Connecticut - CCSPC (Note: CCSPC is an abbreviation for Centralized Child Support Processing Center) Send check to: Connecticut - CCSPC, P.O. Box 990032, Hartford, CT 06199-0032 Authorized by: Date: Date: Print Name and Title of Authorized Official(s): IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. JD-FM-1 Rev. 6/04 Page 1 of 3 <<<<<<<<<********>>>>>>>>>>>>> 2 TRIBUNAL/CASE NO. (To be completed by preparer) ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS 5 If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned busin esses located on a reservation that choose to withhold in accordance with this notice. 2. Priority: Withholding under this Order has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the State Child Support E nforcement Agency or party listed in number 12 below. 3. Combining Payments: You can combine withheld amounts from more than one employees/obligors 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. 4. Reporting the Pay date/Date of Withholding: You must report the pay date/date of withholding when sending the payment. The pay date/date of withholding is the date on which the amount was withheld from the employees wages. You must comply with the law of the state of employees/obligors principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 5. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Orders due to Federal or State withholding limits, you must follow the law of the state of employees/obligors principal place of employment. You must honor all Orders to the greatest extent possible. (See #10 below.)6. Termination Notification: You must promptly notify the Child Support Enforcement Agency or payee when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this Order to the Child Support Enforcement Agency or payee. EMPLOYEES/OBLIGORS NAME: CASE IDENTIFIER: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: 7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. Liability: If you have any doubts about the validity of the Order, contact the agency or person listed below. If you fail to withhold income as the Order directs, you are liable for both the accumulated amount you should have withheld from the employees/obligors income and any other penalties set by State law. Pursuant to C.G.S. 52-362(f), you have a legal duty to make deductions from the obligors income and pay any amou nts deducted as required by this withholding order. If you do not, legal action may be taken against you. If such an action is taken, you may be liable for the full amount not withheld since receipt of proper notice. You may also be subject to a finding of contempt by the court or family support magistrate for failure to honor any terms of this withholding order. 9. Anti-discrimination: You are s
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