Free CASE INPUT RECORD -- NON IV-D INCOME WITHHOLDING - Connecticut

CASE INPUT RECORD NON IV-D INCOME WITHHOLDING
JD-FM-150 Rev. 3-09 C.G.S. § 52-362 Judicial District

Instructions 1. See detailed instructions below. 2. Print legibly with ball point pen.
Docket Number

Court Location (Number, street, town and zip code)

Obligee (Person to Receive Money)
Name (Last, first, middle initial) Street City/Town Telephone Number State Zip Code

Obligor (Person to Pay Money)
Name (Last, first, middle initial) Street City/Town Telephone Number of Obligor State Zip Code

Relationship to Obligor

Telephone Number of Employer or Payer of Income

Social Security Number (Required - see notice below) Date of Birth Ethnic Group Sex

Social Security Number (Required - see notice below) Date of Birth Ethnic Group Sex

M

F

M

F

Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is requested under Connecticut General Statutes §§ 52-362 and 17b-179. It will be used by the Bureau of Child Support Enforcement to ensure the proper collection, verification and distribution of support under Connecticut General Statutes § 17b-179. Child(ren)'s Name(s):
(As listed in support order)

Child(ren)'s Name(s): Date of Birth 5. 6. 7. 8.
Print Name Date Signed

(As listed in support order)

Date of Birth

1. 2. 3. 4.
Signed (Preparer)

Income withholding must be provided in all child support cases. The Judicial District Clerk's Office will provide the required forms. Once the income withholding of child support orders in Non IV-D cases is started, the withheld income of the obligor (the person who owes the money) must be sent by the payer of income to the State Disbursement Unit (not to the obligee) which will send the money to the obligee. You do not have to pay for the administration of Non IV-D income withholding. The Support Enforcement Services, Child Support Call Center (SES) must be told about all changes/modifications to the income withholding, including orders to end the income withholding, and of all employer changes. You must follow instructions below whenever these types of changes occur. (Full IV-D child support enforcement services are available at no cost to you when you apply at a local office of the Department of Social Services. For more information about IV-D services, call the Support Enforcement Services, Child Support Call Center (SES) at 1-800-228-KIDS (5437).)

Instructions
1. 2. 3. 4. Fill out the top part of this form. Fill out the Order/Notice to Withhold Income for Child Support form (JD-FM-1). Give the filled out Order/Notice to Withhold Income for Child Support (JD-FM-1) to the Clerk's Office for the clerk to review and sign. After the Order/Notice to Withhold Income for Child Support (JD-FM-1) is signed by the Clerk and returned to you, give that form and this form to the Support Enforcement Services, Child Support Call Center (SES), P.O. Box 65, Vernon, CT 06066. This will allow SES to enter the necessary information to set up an account in a system used to track child support payments and set up an electronic file (an account in that system). If you do not give both forms to SES, the State Disbursement Unit will not be able to process your immediate income withholding payments. The Order/Notice to Withhold Income for Child Support will be served on the obligor's payer of income by an authorized employee of Support Enforcement Services or other person allowed by statute under section 52-362 of the statutes, or by certified mail, return receipt requested. Keep a copy of all papers for your own records. If the obligor (person who owes money) did not file a written Appearance and an immediate income withholding was ordered, you must fill out a Notice to Nonappearing Obligor of Income Withholding Order (JD-FM-70) form. Attach the "proof of service" of the JD-FM-70 to a copy of that form and file it with the Clerk's Office. Unless otherwise ordered by the Court or Family Support Magistrate, the notice of income withholding order must then be served on the obligor. If you have any questions about the income withholding, call the Support Enforcement Services, Child Support Call Center (SES) at 1-800-228-KIDS (5437).
DISTRIBUTION: ORIGINAL - SES COPY - For Your Records

5. 6.

7.

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