NAME: _____________________________________ ADDRESS: _________________________________ ___________________________________________ ___________________________________________ TEL. No.:___________________________________ [ [ ] Plaintiff/Petitioner Pro Se ] Defendant/ Respondent Pro Se
IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I ) _______________________________, ) [ ] Plaintiff [ ] Petitioner ) ) ) vs. ) ) ) ________________________________, ) [ ] Defendant [ ] Respondent ) ______________________________________ ) FC-___ No. ___________________ [ ] ORIGINAL [ ] AMENDED [ ] TERMINATION ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT
[ ] ORIGINAL [ ] AMENDED [ ] TERMINATION ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT
[X]ORDER/NOTICE TO W ITHHOLD INCOME FOR CHILD SUPPORT [ ]NOTICE OF AN ORDER TO W ITHHOLD INCOME FOR CHILD SUPPORT [ ] Original [ ] Amended [ ] Termination Date: [X] State/Tribe/Territory HAWAI`I - FAMILY COURT OF THE FIRST CIRCUIT
City/Co./Dist./Reservation CITY AND COUNTY OF HONOLULU
[ ] Non-governmental entity or Individual
Case Num ber FCNo. RE: Em ployer's/W ithholder's Nam e Employee's/Obligor's Nam e (Last, First, MI) Em ployee's/Obligor's Social Security Num ber FCNo. Em ployee's/Obligor's Case Identifier Obligee's Nam e (Last, First, MI)
Em ployer's/W ithholder's Address Em ployer's/W ithholder's Federal EIN Num ber (if known)
ORDER INFORMATION: This docum ent is based on the support or withholding order from HAW AII. You are required by law to deduct these am ounts from the em ployee's/obligor's incom e until further notice. __________ __________ __________ __________ __________ __________ __________ Per Per Per Per Per Per Per month month month month month month month current child support past-due child support current cash medical support past-due cash medical support spousal support past-due spousal support other (specify)
Arrears greater than 12 weeks? [ ] yes [ ] no
for a total of __________ per month to be forwarded to the payee below. You do not have to vary your pay cycle to be in com pliance with the support order. If your pay cycle does not m atch the ordered paym ent cycle, withhold one of the following am ounts: __________ per weekly pay period. ______ per biweekly pay period (every two weeks). __________ per semimonthly pay period (twice a month). ____________________________ per monthly pay period.
REMITTANCE INFORMATION: W hen rem itting paym ent, provide the pay date/date of withholding and the case identifier. If the em ployee's/obligor's principal place of em ploym ent is HAW AII, begin withholding no later than the first pay period occurring 7 days after the date of receiving this notice/order. Send paym ent within 5 working days of the pay date/date of withholding. The total withheld am ount, including your fee, m ay not exceed __________% of the em ployee's/obligor's aggregate disposable weekly earnings. If the em ployee's/obligor's principal place of em ploym ent is not HAW AII for lim itations on withholding, applicable tim e requirem ents, and any allowable em ployer fees, follow the laws and procedures of the em ployee's/obligor's principal place of em ploym ent (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER W ITHHOLDERS). Make check payable to: CHILD SUPPORT ENFORCEMENT AGENCY Case ________________ Send check to: CHILD SUPPORT ENFORCEMENT AGENCY STATE DISBURSEMENT UNIT P. O. BOX 1860 HONOLULU, HI 96805-1860 . If rem itting paym ent by EFT/EDI, call (808) 692-7013 before first subm ission. Use this FIPS code: Bank account num ber: Bank routing num ber:
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If this is an Order/Notice to W ithhold: Print Nam e Title of Issuing Official JUDGE, FAMILY COURT, FIRST CIRCUIT
Signature and Date
[ ] IV-D Agency [X] Court [ ] Attorney with authority under state law to issue order/notice.
NOTE: Non-IV-D Attorneys, individuals, and non-governm ental entities m ust subm it a N otice of an Order to W ithhold and include a copy of the incom e withholding order unless, under a state's law, an attorney in that state m ay issue an incom e withholding order. In that case, the attorney m ay subm it an Order/Notice to W ithhold and include a copy of the state law authorizing the attorney to issue an incom e withholding order/notice. IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
[ ]If checked, you are required to provide a copy of this form to your employee/obligor. 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/obligor even if the box is not checked. 1. Priority: Withholding under this Order or Notice has priority over any other legal process under state law (or tribal law, if applicable) against the same income. If there are federal tax levies in effect, please notify the contact person listed below. (See 10 below.) 2. Combining Payments: You may combine withheld amounts from more than one employee's/obligor's 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. 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 amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments. 4. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order or Notice against this employee/obligor and you are unable to honor all support Orders or Notices due to federal, state, or tribal withholding limits, you must follow the state or tribal law/procedure of the employee's/obligor's principal place of employment. You must honor all Orders or Notices to the greatest extent possible. (See 9 below.) 5. Termination Notification: You must promptly notify the Child Support Enforcement (IV-D) Agency and/or the contact person listed below when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this Order or Notice to the Child Support Enforcement (IV-D) Agency and/or the contact person listed below. (See 10 below.) THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: EMPLOYEE'S/OBLIGOR'S NAME: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: CASE IDENTIFIER:
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 Child Support Enforcement (IV-D) Agency. 7. Liability : If you have any doubts about the validity of the Order or Notice, contact the agency or person listed below under 10. If you fail to withhold income as the Order or Notice directs, you are liable for both the accumulated amount you should have withheld from the employee's/obligor's income and any other penalties set by state or tribal law/procedure. This Order/Notice is applicable to all employers and to all income as defined in Sections 571-52(e), 571-52.2(n), 576E-1, and 576E-
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16(f) of the Hawaii Revised Statutes. 8. Anti-discrimination: You are subject to a fine determined under state or tribal 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: For state orders, you may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. § 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, statutory pension contributions, 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 greater than 12 weeks. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. Child(ren)'s Names /DOB and Additional Information:
10. If you or your employee/obligor have any questions, contact CHILD SUPPORT ENFORCEMENT AGENCY - OAHU BRANCH by telephone at 587-4250 ALL OTHERS: 1-888-317-9081 by Fax at (808) 692-7060 or by internet at _________________.
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