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Distribution of Federally Approved Interstate Subpoena Form and Notice of Interstate Lien Form

AT-97-03

Published: March 7, 1997
Information About:
State/Local Child Support Agencies
Topics:
Case Management, Enforcement, Intergovernmental/Interstate
Types:
Policy, Action Transmittals (AT)
Tags:
Collection & Enforcement Systems, Lien and Levy

Interstate Forms, Subpoena and Notice of Interstate Lien

ACTION TRANSMITTAL

OCSE-AT-97-03

March 7, 1997

TO: STATE AGENCIES ADMINISTERING CHILD SUPPORT ENFORCEMENT PLANS UNDER TITLE IV-D OF THE SOCIAL SECURITY ACT AND OTHER INTERESTED INDIVIDUALS

SUBJECT:Distribution of Federally approved interstate forms: Interstate Subpoena and Notice of Interstate Lien.

ATTACHMENT:Attached are copies of the Interstate Subpoena form and instructions, and the Notice of Interstate Lien form and instructions. Forms and instructions are distributed via hard copy and electronic (WordPerfect 5.1) format.

STATUTORY

REFERENCE:42 U.S.C. 642(a)(11) and 42 U.S.C. 654(9)(E), as amended by section 324 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, PL 104-193.

BACKGROUND:Section 324 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, PL 104-193, amends Title IV, Part D, of the Federal Social Security Act to require the Federal Office of Child Support Enforcement (OCSE) to promulgate new interstate child support enforcement forms and, effective March 1, 1997, mandate the use of these forms by the State IV-D programs. Two of these forms are the Interstate Subpoena and the Notice of Interstate Lien. Effective March 3, 1997, the Federal Office of Management and Budget approved the attached forms pursuant to emergency clearance procedures under 5 C.F.R. 1320.13. The State IV-D programs are directed to use the attached forms as appropriate.

INQUIRIES: ACF Regional Administrators

David Gray Ross

Deputy Director

Office of Child Support

Enforcement

OMB Control #: 0970-0152

Expiration Date: 09-30-97

Interstate Subpoena

TO:

REGARDING:

Case Caption:

FROM:

Issuing State Case Number:

Under Federal law (42 U.S.C. 666(c)(1)), the law of the issuing state ( ) and similar statutes in all other states, the undersigned COMMANDS you to provide financial or other information needed to establish, modify, or enforce a support order.

Provide the following information or documents:

to the agent issuing this subpoena by this date:

The information or documents may be mailed or sent by facsimile transmission. Your response to this subpoena must be dated, signed by you or your designee, and be [ ] notarized - [ ] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)."

The undersigned states that, as an authorized agent of a state or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any state. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws of your state. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency (see the "FROM" field, above) and reference the issuing state case number.

Date Authorized Agent

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

Instructions For the Notice of Interstate Lien

To complete this form:

1.In the "TO" field, place the name and address of the office or entity (i.e., County Auditor, Clerk of Court, DMV, etc.) to which you are sending the lien.

NOTE:The procedures of the state where the property is located determine which office or entity in that state is the appropriate one to receive the lien for filing. It is the responsibility of the agency/office issuing the lien to file it with the appropriate entity.

2.In the "OBLIGOR" field, place the obligor's full name, DOB, and SSN (if known). Include known aliases or multiple SSNs used by the obligor.

3.In the "FROM (Claimant)" field: insert the name, address and phone/fax numbers of the office that is issuing this lien.

4.In the "Claimant's Case #" field: insert the IV-D or other appropriate case number.

5. In the space following "entered on": insert the date of entry of the order which is the basis for the lien.

6.In the space following "by": identify the name of the tribunal (court or administrative) that issued the support order which is being used to determine the amount of the lien.

7.In the space following "in": identify the location (State/county) of the tribunal that issued the support order that is being used to determine the amount of the lien.

8.In the space following "docket number": identify the tribunal docket, jacket or file number of the support order that is used to determine the amount of the lien.

9.In the space following "in the amount of $": insert the amount of the current/prospective support obligation.

10.In the space following "per": identify the frequency (month/week, etc.) with which the current support is ordered to be paid.

11.In the space following "As of": insert the date of the debt calculation that is used in determining the amount of the lien.

12.In the space following "amount of $": insert the lien amount (the amount ofthe past-due support obligation owed when the lien is prepared) .

13.In the space following "interest rate of": insert the interest rate (if any) that is being assessed to the child support debt.

14.If applicable, in the space following "Specific description of property", identify any specific property that you want the lien to attach to. Use the legal description of real property and, when the target of the lien is personal property, always provide the most specific identifying information available, including the location of the property, if known. (For example, include the make/model/year/appropriate registration numbers (if known), as opposed to referring to such personal property as "farm equipment".)

15.Provide the date the lien is signed on the line provided above "date".

16.The appropriate individual signs the lien on the line above "Authorized Agent". Type or print the name of the agent signing the lien below their signature.

17.Have the signature of the individual signing the lien notarized.

18.Send a copy of the lien to the obligor at his/her last known address.

The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. Submit the Order/Notice to employers in States that have adopted the Uniform Interstate Family Support Act (UIFSA) or have similar State laws.

The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information.

1a.Name of your State or territory.

1b.Name of your jurisdiction.

2.Date the Order/Notice to Withhold is to be mailed.

3.Identifying number used by the court/agency issuing this Order/Notice, if appropriate.

4 a-c.Check the appropriate case status of the Order/Notice to Withhold.

5.Employer/Withholder's nine digit Federal employer identification number (if available). Include three digit location code (if known).

6a.Employer/Withholder's name.

6b-e.Employer/Withholder's mailing address. (This may differ from the Employee/Obligor work site.)

7.Employee/Obligor's last name, first name, and middle initial (if known).

8.Employee/Obligor's Social Security Number.

9.Case identifier (or other identifier) used for recording the payment. (May be the same as #3.)

10.Custodial Parent's last name, first name, and middle initial (if known).

11.Child(ren)'s name(s) and date of birth listed in the support order.

ORDER INFORMATION:

12.Name of State that issued the underlying child support order.

13.Termination date of the support order.

14.Check if the child support order requires enrollment of the child(ren) in any health insurance coverage available the employee's/obligor's employment. If the obligor is a Federal government employee, please do not check the box provided. The space is provided for instructions, i.e. see attached form.

Instructions to complete the Order/Notice - continued

15a.Dollar amount to be withheld for payment of current child support.

15b.Time period that corresponds to the amount in #15a (e.g., month).

16a.Dollar amount to be withheld for payment of past-due child support under your State law.

16b.Time period that corresponds to the amount in #16a (e.g., month).

17a.Dollar amount to be withheld for payment of medical support, as appropriate, based on the underlying order.

17b.Time period that corresponds to the amount in #17a (e.g., month).

18a.Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order.

18b.Time period that corresponds to the amount in #18a (e.g., month).

18c.Describe the amount(s) represented in #18a separately by fee type (e.g., court fees).

19a.Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order and time period that corresponds to the amount in #19a (e.g., month).

19b.Time period that corresponds to the amount in #19a (e.g., month).

19c.Describe the amount(s) represented in #19a separately by fee type (e.g., court fees).

20a.Total of #15a, #16a, #17a, #18a, and #19a.

20b.Time period that corresponds to the amount in #15b (e.g., month).

21.Check this box if arrears are 12 weeks or greater.

22a.Amount an employer withholds if the employee is paid weekly.

22b.Amount an employer withholds if the employee is paid every two weeks.

22c.Amount an employer withholds if the employee is paid twice a month.

22d.Amount an employer withholds if the employee once a month.

REMITTANCE INFORMATION:

23.Number of days in which the withholding must begin pursuant to the law of your State.

24.Number of working days an employer or other payor of income must remit amounts withheld pursuant to the law of your State.

25.Amount or percentage that an employer or other payor of income may deduct in addition to child support from its payment as a fee for withholding child support pursuant to the law of your State. If your State does not permit deduction of a fee, enter 0. Employers with employees/obligors located in another State should know those State laws.

Instructions to complete the Order/Notice - continued

26.Maximum percentage that can be withheld based on the applicable withholding limit of your State. If the employer is a Federal agency and you add the additional 5 percentage points allowed under the Federal Consumer Credit Protection Act to the percentage entered for #22 (i.e., 65%; or 55% instead of 50% if the obligor supports a second family), check #14c on the Order/Notice to indicate the support is 12 weeks or more in arrears.

27a.Case identifier or other identifier. (May be the same as #3 and/or #9.)

27b.Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters that identifies the State and county. It is seven characters when it identifies the State, county, and a location within the county. It is necessary for centralized collections. Complete only for EFT/EDI transmission.

27c.Receiving agency's bank routing number. Complete only for EFT/EDI transmission.

27d.Receiving agency's bank account number. Complete only for EFT/EDI transmission.

28a.Name of the child support enforcement agency to which payments are made and the case identifier on the payment line.

28b-d. Street address, City, and State of the child support enforcement agency identified in #28a.

29a.Signature of official(s) authorized to send the Order/Notice. This line is optional if a signature is not required by State statute.

29b.Print name of the official(s) authorized to send the Order/Notice.

30.Check the box if the employer is to provide a copy of the Order/Notice to the employee.

31.Penalty and your State citation for an employer who fails to comply with the Order/Notice. Your State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.

32.Penalty and your State citation for an employer who discharges, refuses to employ, or disciplines an employee/obligor as a result of the Order/Notice. Your State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.

33.Use this space to provide the employer with additional information.

34a.Name of the agency or court requesting the income withholding.

34b-e. Address of the agency or court requesting the income withholding.

35a.Name of the child support enforcement agency's contact person who an employer and/or employee/obligor may call for information regarding the Order/Notice.

Instructions to complete the Order/Notice - continued

35b.Telephone number of the contact person who an employer may call for information regarding the Order/Notice.

35c.Facsimile number for the person whose name appears in #35a.

35d.Internet address for the person whose name appears in 35a.

If the employer is a Federal Government agency the following instructions apply.

þ Serve the Order/Notice upon the governmental agent listed in 5 CFR part 581, appendix A.

þ Sufficient identying information must be provided in order for the obligor to be identified. It is, therefore, recommended that the forllowing information, if known and if applicable, be provided: (1) full name of the obligor; (2) date of birth; (3) employment number, Department of Veterans Affairs claim number, or civil service retirement claim number; (4) component of the government entity for which the obligor works, and the official duty station or worksite; and (5) status of the obligor, e.g., employee, former employee, or annuitant.

þ You may withhold from a variety of income and forms of payment, including voluntary separation incentive payments (buyout payments), incentive pay, and cash awards. For a more complete list see 5 CFR 581.103.

******************************************

The Paperwork Reduction Act of 1995

This information collection is conducted in accordance with 45 CFR 303.7 of the child support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

State 1a , 4a Original Order/Notice

Co./City/Dist. of 1b 4b Amended Order/Notice

Date of Order/Notice 2 4c Terminate Order/Notice

Court/Case Number 3

5 ) RE: * 7

Employer/Withholder's Federal EIN Number )Employee/Obligor's Name (Last, First, MI)

6a ) * 8

Employer/Withholder's Name )Employee/Obligor's Social Security Number

6b ) * 9

Employer/Withholder's Address )Employee/Obligor's Case Identifier

6c ) 10

6d ) Custodial Parent's Name (Last, First, MI)

6e )

Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB

11

ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from

12 . By law, you are required to deduct these amounts from the above-named employee's/obligor's income until 13 even if the Order/Notice is not issued by your State.

_ If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. 14

$ 15a per 15b in current support

$ 16a per 16b in past-due support 21 Arrears 12 weeks or greater? _ yes _ no

$ 17a per 17b in medical support

$ 18a per 18b in other (specify) 18c

19a per 19b in other (specify) 19c

for a total of $ 20a per 20b 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 support payment cycle, use the following to determine how much to withhold:

$ 22a per weekly pay period. $ 22c per semimonthly pay period (twice a month).

$ 22b per biweekly pay period (every two weeks). $ 22d per monthly pay period.

REMITTANCE INFORMATION: Follow the laws and procedures of the employee's/obligor's principal place of employment even if such laws and procedures are different from this paragraph:

You must begin withholding no later than the first pay period occurring 23 working days after the date of this Order/Notice. Send payment within 24 working days of the paydate/date of withholding. You are entitled to deduct a fee of 25 to defray the cost of withholding. You are entitled to deduct a fee of to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed 26 % the employee/obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 on back):

When remitting payment provide the paydate/date of withholding and the case identifier 27a .

If remitting by EFT/EDI, use this FIPS code: * 27b ; Bank routing code:* 27c ;

Bank account number:* 27d .

Make it payable to: 28a Payee and case identifier

Send check to: 28b Payee's Address

28c

28d

Authorized by 29a

Print Name 29b

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

30_ If checked you are required to provide a copy of this form to your employee.

1.Priority: Withholding under this Order/Notice 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 requesting agency listed below.

2.Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

3.Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the employee is paid and controls the income, i.e. the date the income check or cash is given to the employee, or the date in which the income is deposited directly in his/her account.

4.Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/Notice against this employee/obligor and you are unable to honor them all in full because together they exceed the withholding limit of the State of the employee's principal place of employment (see #9 below), you must allocate the withholding based on the law of the State of the employee's principal place of employment. If you are unsure of that State's allocation law, you must honor all Orders/Notices' current support withholdings before you withhold for any arrearages, to the greatest extent possible under the withholding limit. You should immediately contact the last agency that sent you an Order/Notice to find the allocation law of the state of the employee's principal place of employment.

5.Termination Notification: You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this order/notice to the agency identified below.

EMPLOYEE'S/OBLIGOR'S NAME:

EMPLOYEE'S CASE IDENTIFIER: DATE OF SEPARATION: .

LAST KNOWN HOME ADDRESS . NEW EMPLOYER'S ADDRESS .

6.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.

7.Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and any other penalties set by State law.

31

8.Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding.

32

9.Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. õ 1673(b)); or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by: 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears are more than 12 weeks old. (see boxes on front)

10.33

Requesting Agency 34a

34b

34c

34d

34e

If you or your employee/obligor have any questions, contact:

35a

by telephone at 35b or

by FAX at 35c or

by Internet 35d .

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

State , Original Order/Notice

Co./City/Dist. of Amended Order/Notice

Date of Order/Notice Terminate Order/Notice

Court/Case Number

) RE: *

Employer/Withholder's Federal EIN Number )Emplo yee/O bligor' s Name (Last, First, MI)

) *

Employer/Withholder's Name ) Employee/Obligor's Social Security Number

) *

Employer/Withholder's Address ) Employee/Obligor's Case Identifier

)

) Custodial Parent's Name (Last, First, MI)

)

Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB

ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from

. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until even if the Order/Notice is not issued by your State.

_ If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment.

$ per in current support

$ per in past-due support Arrears 12 weeks or greater? _ yes _ no

$ per in medical support

$ per in other (specify)

per in 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 support payment cycle, use the following to determine how much to withhold:

$ per weekly pay period. $ per semimonthly pay period (twice a month).

$ per biweekly pay period (every two weeks). $ per monthly pay period.

REMITTANCE INFORMATION: Follow the laws and procedures of the employee's/obligor's principal place of employment even if such laws and procedures are different from this paragraph:

You must begin withholding no later than the first pay period occurring working days after the date of this Order/Notice. Send payment within working days of the paydate/date of withholding. You are entitled to deduct a fee of to defray the cost of withholding. You are entitled to deduct a fee of to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed % the employee/obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 on back):

When remitting payment provide the paydate/date of withholding and the case identifier .

If remitting by EFT/EDI, use this FIPS code: * ; Bank routing code:* ;

Bank account number:* .

Make it payable to: Payee and case identifier

Send check to: Payee's Address

Authorized by

Print Name

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

_ If checked you are required to provide a copy of this form to your employee.

1.Priority: Withholding under this Order/Notice 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 requesting agency listed below.

2.Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

3.Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the employee is paid and controls the income, i.e. the date the income check or cash is given to the employee, or the date in which the income is deposited directly in his/her account.

4.Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/Notice against this employee/obligor and you are unable to honor them all in full because together they exceed the withholding limit of the State of the employee's principal place of employment (see #9 below), you must allocate the withholding based on the law of the State of the employee's principal place of employment. If you are unsure of that State's allocation law, you must honor all Orders/Notices' current support withholdings before you withhold for any arrearages, to the greatest extent possible under the withholding limit. You should immediately contact the last agency that sent you an Order/Notice to find the allocation law of the state of the employee's principal place of employment.

5.Termination Notification: You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this order/notice to the agency identified below.

EMPLOYEE'S/OBLIGOR'S NAME:

EMPLOYEE'S CASE IDENTIFIER: DATE OF SEPARATION: .

LAST KNOWN HOME ADDRESS . NEW EMPLOYER'S ADDRESS .

6.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.

7.Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and any other penalties set by State law.

8.Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding.

9.Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. õ 1673(b)); or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes;and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by: 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears are more than 12 weeks old. (see boxes on front)

10.

Requesting Agency

If you or your employee/obligor have any questions, contact:

by telephone at or

by FAX at or

by Internet .

OMB Control #: 0970-0152

Expiratio n Date: 09-30-97

Interstate Subpoena

TO:1

REGARDING: 2

Case Caption: 3

FROM: 4

Issuing State Case Number: 5

Under Federal law (42 U.S.C. 666(c)(1)), the law of the issuing state ( 6 ) and similar statutes in all other states, the undersigned COMMANDS you to provide financial or other information needed to establish, modify, or enforce a support order.

Provide the following information or documents: 7

to the agent issuing this subpoena by this date: 8

The information or documents may be mailed or sent by facsimile transmission. Your response to this subpoena must be dated, signed by you or your designee, and be [9] notarized - [10] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)."

The undersigned states that, as an authorized agent of a state or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any state. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws of your state. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency (see the "FROM" field, above) and reference the issuing state case number.

11 12

Date Authorized Agent

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control #: 0970-0153

NOTICE OF INTERSTATE LIEN

TO:

OBLIGOR:

FROM (Claimant):

Claimant's Case #:

This lien results from a child support order, entered on by in docket number . This order requires the above-named obligor to pay child support in the amount of $ per .

As of , the obligor owes unpaid support in the amount of $ , and this lien amount is subject to an interest rate of .

Prospective amounts of child support, not paid when due, are judgments and accrue to the lien amount. This lien attaches to all non-exempt real and personal property of the above-named obligor which is located or existing within the state/county of filing, including any property specifically described below.

Specific description of property:

All aspects of this lien, including its priority and enforcement, are governed by the law of the state where the property is located. This lien remains in effect until released by the claimant or in accordance with the laws of the state of filing.

For use by Lien Recorder

As an authorized agent of a state, or subdivision of a state, agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651 et seq.), I have authority to file this child support lien in any state, or U.S. Territory. For additional information regarding this lien, including the pay-off amount, please contact the authorized agency (claimant) and reference its case number, both listed above.

Date Authorized Agent

State of )

)ss.

County of )

I certify that appeared before me and is known to me at the individual who signed the above.

Date:

Notary Public

My appointment expires

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control #: 0970-0152

Expiration Date: 09-30-97

Interstate Subpoena

TO:1

REGARDING: 2

Case Caption: 3

FROM: 4

Issuing State Case Number: 5

Under Federal law (42 U.S.C. 666(c)(1)), the law of the issuing state ( 6 ) and similar statutes in all other states, the undersigned COMMANDS you to provide financial or other information needed to establish, modify, or enforce a support order.

Provide the following information or documents: 7

to the agent issuing this subpoena by this date: 8

The information or documents may be mailed or sent by facsimile transmission. Your response to this subpoena must be dated, signed by you or your designee, and be [9] notarized - [10] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)."

The undersigned states that, as an authorized agent of a state or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any state. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, as provided under the laws of your state. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency (see the "FROM" field, above) and reference the issuing state case number.

11 12

Date Authorized Agent

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

OMB Control #: 0970-0152

Expiration Date: 09-30-97

Interstate Subpoena

TO:1

REGARDING: 2

Case Caption: 3

FROM: 4

Issuing State Case Number: 5

Under Federal law (42 U.S.C. 666(c)(1)), the law of the issuing state ( 6 ) and similar statutes in all other states, the undersigned COMMANDS you to provide financial or other information needed to establish, modify, or enforce a support order.

Provide the following information or documents: 7

to the agent issuing this subpoena by this date: 8

The information or documents may be mailed or sent by facsimile transmission. Your response to this subpoena must be dated, signed by you or your designee, and be [9] notarized - [10] witnessed with the following statement:

"I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date)."

The undersigned states that, as an authorized agent of a state or county agency responsible for implementing the child support enforcement program set forth in Title IV, Part D, of the Federal Social Security Act (42 U.S.C. 651, et seq.), I have legal authority to issue this subpoena to have effect in any state. Failure to obey this subpoena may result in the imposition of penalties, including fines or imprisonment, asprovided under the laws of your state. For additional information regarding this subpoena, including how to challenge it, please contact the issuing agency (see the "FROM" field, above) and reference the issuing state case number.

11 12

Date Authorized Agent

Notice: Respondents are not required to respond to this information collection unless it displays a valid OMB control number. The average burden for responding to this information collection is estimated at 30 minutes. If you believe this estimate is inaccurate, or if you have ideas to reduce this burden, please provide comment to the issuing agency.

Instructions for the Interstate Subpoena

To complete this form:

1.Place, in the "TO" field, the name and address of the individual or entity on whom you are serving the subpoena. (Frequently, this will be an employer.)

2.Place, in the "REGARDING" field, the name, dob, and SSN (if available) of the individual you are requesting information about. (Frequently, this will be the noncustodial parent.)

3.Place, in the "Case Caption" field, the title of the proceeding (i.e., John Doe v. Jane Doe), under which you are issuing the subpoena.

4.Place, in the "FROM" field, the name of the IV-D office issuing the subpoena, including its address/phone/fax numbers.

5.Provide the IV-D case number, or other case identifier, in the space following "Issuing State Case Number".

6.Insert the citation for your State statute that allows you to issue an interstate subpoena.

7.Clearly, completely, and specifically describe all records or documents that you are requesting the individual receiving the subpoena provide.

8.Provide the date that the requested documents are to be provided to you.

9.Check the "notarized" box if you require notarized documents.

10.Check the "witnessed" box if you do not require notarized documents.

11.Place the date the subpoena is signed in the "date" field.

12.Have the person issuing the subpoena sign in the "signature" field.

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

State , Original Order/Notice

Co./City/Dist. of Amended Order/Notice

Date of Order/Notice Terminate Order/Notice

Court/Case Number

) RE: *

Employer/Withholder's Federal EIN Number )Emplo yee/O bligor' s Name (Last, First, MI)

) *

Employer/Withholder's Name ) Employee/Obligor's Social Security Number

) *

Employer/Withholder's Address ) Employee/Obligor's Case Identifier

)

) Custodial Parent's Name (Last, First, MI)

)

Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB

ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from

. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until even if the Order/Notice is not issued by your State.

_ If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment.

$ per in current support

$ per in past-due support Arrears 12 weeks or greater? _ yes _ no

$ per in medical support

$ per in other (specify)

per in 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 support payment cycle, use the following to determine how much to withhold:

$ per weekly pay period. $ per semimonthly pay period (twice a month).

$ per biweekly pay period (every two weeks). $ per monthly pay period.

REMITTANCE INFORMATION: Follow the laws and procedures of the employee's/obligor's principal place of employment even if such laws and procedures are different from this paragraph:

You must begin withholding no later than the first pay period occurring working days after the date of this Order/Notice. Send payment within working days of the paydate/date of withholding. You are entitled to deduct a fee of to defray the cost of withholding. You are entitled to deduct a fee of to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed % the employee/obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 on back):

When remitting payment provide the paydate/date of withholding and the case identifier .

If remitting by EFT/EDI, use this FIPS code: * ; Bank routing code:* ;

Bank account number:* .

Make it payable to: Payee and case identifier

Send check to: Payee's Address

Authorized by

Print Name

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

_ If checked you are required to provide a copy of this form to your employee.

1.Priority: Withholding under this Order/Notice 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 requesting agency listed below.

2.Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

3.Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the employee is paid and controls the income, i.e. the date the income check or cash is given to the employee, or the date in which the income is deposited directly in his/her account.

4.Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/Notice against this employee/obligor and you are unable to honor them all in full because together they exceed the withholding limit of the State of the employee's principal place of employment (see #9 below), you must allocate the withholding based on the law of the State of the employee's principal place of employment. If you are unsure of that State's allocation law, you must honor all Orders/Notices' current support withholdings before you withhold for any arrearages, to the greatest extent possible under the withholding limit. You should immediately contact the last agency that sent you an Order/Notice to find the allocation law of the state of the employee's principal place of employment.

5.Termination Notification: You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this order/notice to the agency identified below.

EMPLOYEE'S/OBLIGOR'S NAME:

EMPLOYEE'S CASE IDENTIFIER: DATE OF SEPARATION: .

LAST KNOWN HOME ADDRESS . NEW EMPLOYER'S ADDRESS .

6.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.

7.Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and any other penalties set by State law.

8.Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding.

9.Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. õ 1673(b)); or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes;and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by: 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears are more than 12 weeks old. (see boxes on front)

10.

Requesting Agency

If you or your employee/obligor have any questions, contact:

by telephone at or

by FAX at or

by Internet .