INSTRUCTION FORM FOR ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information. The person or agency completing this form may cross out the word "Order" or "Notice" if that term is inappropriate under the law of the issuing state.

1a. Check the appropriate status of the Order/Notice to Withhold.
1b. Name of the issuing State or territory.
1c. Name of the order issuing tribunal or other jurisdictional designation if any used by the order issuing State.
1d. Identifying number used by the court/agency issuing this Order/Notice, if appropriate.

2a. Employer’s/Withholder's name.
2b-c. Employer’s/Withholder's mailing address, city, and state. (This may differ from the Employee/Obligor work site.)
2d. Employer’s/Withholder's nine-digit Federal employer identification numbers (if available). Include three-digit location code.

3a. Employee’s/Obligor's last name, first name, and middle initial.
3b. Employee’s/Obligor's Social Security Number (if known).
3c. The identifier used by the order issuing state for recording payments. (May be the same as #1d.)
3d. Custodial Parent's last name, first name, and middle initial (if known).

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

5. Check if the child support order requires enrollment of the child(ren) in any health insurance coverage available to the employee's/obligor's through his/her employer. (The space on the form is provided for instructions to the employer, i.e. "see attached medical support form.")

ORDER INFORMATION:

6. Name of State that issued the order.

7a. Dollar amount to be withheld for payment of current child support.
7b. Time period that corresponds to the amount in #7a (such as month, week, etc.).

8a. Dollar amount to be withheld for payment of past-due child support under State law.
8b. Time period that corresponds to the amount in #8a (such as month, week, etc.).

9a. Dollar amount to be withheld for payment of current medical support, as appropriate, based on the underlying order.
9b. Time period that corresponds to the amount in #9a (such as month, week, etc.).

10a. Dollar amount to be withheld for payment of past-due medical support, if appropriate, based on the underlying order.
10b. Time period that corresponds to the amount in #10a (such as month, week, etc.).

11a. Dollar amount to be withheld for payment of spousal support (alimony), if appropriate based on the underlying order.
11b. Time period that corresponds to the amount in 11a (such as month, week, etc.).

12a-c.Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order, time period that corresponds to the amount in #13a (e.g., month), and describe the miscellaneous obligation.

13a. Total of #7a, #8a, #9a, #10a, 11a, and # 12a.
13b. Time period that corresponds to the amount in #13a (e.g., month).

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

15a. Amount an employer should withhold if the employee is paid weekly.
15b. Amount an employer should withhold if the employee is paid every two weeks.
15c. Amount an employer should withhold if the employee is paid twice a month.
15d. Amount an employer should withhold if the employee is paid once a month.

REMITTANCE INFORMATION:

16. The State in which this Order/Notice is issued.

17. Number of days in which the withholding must begin pursuant to the issuing State's law.

18. The effective date of the income withholding.

19. Number of working days within which an employer or other payor of income must remit amounts withheld pursuant to the issuing State's law.

20. Maximum percentage that can be withheld based on the applicable withholding limit of the issuing State. If the Federal Consumer Credit Protection Act laws of the issuing State allows the additional arrearage payment of 5 percentage points to the percentage normally specified in #20 (i.e., 65% instead of 60 or 55% instead of 50% if the obligor supports a second family), use this increased percentage in #20 and check #14 on the Order/Notice to indicate the support is 12 weeks or more in arrears.

21. The State in which this Order/Notice is issued.

22a. The agency’s number for representative to provide EFT/EDI instructions. Contact the court/agency before the first EFT/EDI submission.
22b. Complete only for EFT/EDI transmission. Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters that identify 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.
22c. Complete only for EFT/EDI transmission. Receiving agency's bank routing number.
22d. Complete only for EFT/EDI transmission. Receiving agency's bank account number.

23. Name of the collection unit (State Disbursement Unit), person, or tribunal/court specified in the underlying income withholding order to which payments are required to be sent. This form may not indicate a location other than that specified by an entity authorized under State law to issue an income withholding order. Please include the case identifier used to record payment (may be the same as 3c).

24. Street address, city, and State of the collection unit, person, or tribunal/court identified in #22. This information is shared with the obligor. If you have a confidential address, please contact your IV-D agency.

25a. Signature of official(s) authorizing this Order/Notice. This line may be optional only if the Order/Notice includes the name and title of an official of the State or local IV-D agency on line 24, and a signature of the official is not required by State law.

25b. Date of signature.

26. Print name and title of the official(s) State or local IV-D agency authorizing this Order/Notice.

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

28. Penalty and/or citation for an employer who fails to comply with the Order/Notice. The 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. Use this space to provide State specific information.

29. Penalty and/or citation for an employer who discharges, refuses to employ, or disciplines an employee/obligor as a result of the Order/Notice. The 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. Use this space to provide State specific information.

30. Withholding limits enforced by the Federal Consumer Credit Protection Act (15 U.S.C. § 1673(b)). Use this space to provide State specific information on income withholding limits.

31. Name and address of the State or local IV-D agency, tribunal/court, individual, or private agency submitting the income withholding.

32a. Name of the child support enforcement agency's contact person or party whom an employer and/or employee/obligor may call for information regarding the Order/Notice.

32b. Telephone number of the contact person who an employer may call for information regarding the Order/Notice.

32c. Facsimile number for the person whom appears in #32a.

32d. Internet address for the person whom name appears in 32a.

If the employer is a Federal Government agency, the following instructions apply:

 

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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.