Income Withholding For Support {OMB 0970-0154}

INCOME WITHHOLDING FOR SUPPORT 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 http://www.acf.hhs.gov/programs/cse/forms/OMB-0970-0154_instructions.pdf). 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 _______________________________ _____________________________________________ 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 _____________ (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 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. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is (State/Tribe), days after the date of . Send you must begin withholding no later than the first pay period that occurs working days of the pay date. If you cannot withhold the full amount of support for any or all orders payment within % of disposable income for all orders. If the employee/obligor's principal for this employee/obligor, withhold up to (State/Tribe), obtain withholding limitations, time requirements, and any place of employment is not 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. Document Tracking Identifier_____________________________________ OMB 0970-0154 American LegalNet, Inc. www.FormsWorkFlow.com 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 _____________________________________________________________ (SDU/Tribal Order Payee) at ________________________________________________________________________ (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 Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO inst