FL-195/OMB No. 0970-0154
INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT TERMINATION of IWO Date: _________________
Child Support Enforcement (CSE) Agency Court Attorney Private Individual/Entity (Check One)
NOTE: If you receive this document from someone other than a State or Tribal Child Support Enforcement agency or a court, a copy of the underlying order that contains a provision authorizing income withholding must be attached. Or if under State law an attorney in that State, or if under Tribal law a Tribal legal representative, may issue an income withholding order, the attorney or Tribal legal representative must include a copy of the State or Tribal law authorizing the attorney or Tribal legal representative to issue an income withholding order. State/Tribe/Territory _______________________________ Case Identifier ___________________________________ City/County/Dist./Tribe _______________________________ Order Identifier ___________________________________ Private Individual/Entity________________________________________________________________________________ __________________________________________ Employer/Income Withholder's Name __________________________________________ Employer/Income Withholder's Address ___________________________________________ ___________________________________________ __________________________________________ Employer/Income Withholder's Federal EIN Child's Name (Last, First, MI) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Child's Birth Date __________________ __________________ __________________ __________________ __________________ __________________ RE: _______________________________________________ Employee/Obligor's Name (Last, First, MI) _______________________________________________ Employee/Obligor's Social Security Number (if known) _______________________________________________ Custodial Party/Obligee's Name (Last, First, MI)
ORDER INFORMATION: This document is based on the support or withholding order from ________. 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 of $_____________________ per __________________________________ to be forwarded to the payee below. 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 biweekly pay period (every two weeks) $ $ ___________ per semimonthly pay period (twice a month) $ ___________ per monthly pay period
$__________ ONE-TIME 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 ___________________________ __ . ________, you must begin withholding no later than the first pay period that occurs _______ days after the date of Send payment within __________ working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to ______% of disposable income for all orders. If the employee/obligor's principal place of employment is not ___________________________________, see the ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS for limitations on withholding, applicable time requirements and any allowable employer's fees. Document Tracking Identifier_____________________________________
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FL-195/OMB No. 0970-0154 For EFT/EDI instructions, contact the EFT/EDI office at the website listed below. If paying by check, make check payable to: __________________________________________________________. Include this Remittance Identifier with payment: __________________________. Send check to: _________________________________________________ ___________________________________________________________________________________________________ FIPS code (If necessary): ___________________ Signature (if required by State or Tribal law): _____________________________________________________________ Print Name: ______________________________________________________________________________________ Title of Issuing Official: _____________________________________________________________________________ If checked, you are required to provide a copy of this form to the employee/obligor. 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 must be provided to the employee/obligor even if the box is not checked. ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS State-specific information may be viewed on the OCSE Employer Services website located at: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts.htm Priority: Withholding for support has priority over any other legal process under State law (or Tribal law if applicable) against the same income. If a Federal tax levy is in effect, please notify the contact person listed below. Combining Payments: You may combine withheld amounts from more than one employee/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. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment with respect to the time periods within which you must implement the withholding and forward the support payments. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice against this employee/obligor and you are unable to fully honor all support Orders/Notices due to federal, State, or Tribal withholding limits, you must follow the State or Tribal law/procedure of the employee/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible, giving priority to current support before payment of any past-due support. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. Contact the agency or person listed below to determine if you are required to withhold or if you have any questions about lump sum payments. Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. 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 or Tribal law/procedure. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 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 an employee/obligor because of a child support withholding. _________________________________________________________________________________________ ___________________________________________________________________________________________________ Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of employment. Disposable income 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 limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section.
OMB Expiration Date 10/31/2010. The OMB Expiration Date has no bearing on the termination date or validity of the income withholding Page 2 of 3 order; it identifies the version of the form currently in use.
FL-195/OMB No. 0970-0154 Employee/Obligor's Name: ________________________________ Case Identifier: _______________________________ Order Identifier: ______________________________ Employer's Name: ________________________________________ Arrears greater than 12 weeks? If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. 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 lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Additional Information: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ NOTIFICATION OF TERMINATION OF EMPLOYMENT: You must promptly notify the Child Support Enforcement agency and/or the person listed below by returning this form to the correspondence address if: This person has never worked for this employer. This person no longer works for this employer. Please provide the following information for the terminated employee: Termination date: ___________________ Last known phone number: ______________________________
Last known home address: ______________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Date final payment made to the State Disbursement Unit or Tribal CSE agency: ___________ Final payment amount: __________ New employer's name: ____________________________________ _____________________________________________________________________________________________ New employer's address: _____________________________________________________________________________________________ _____________________________________________________________________________________________ CONTACT INFORMATION To employer: If the employer/income withholder has any questions, contact _____________________________________ ____________________ by phone at ___________________, by fax at ___________________, by email or website at: __________________________________________________________________________________________________. Send termination notice and other correspondence to: __________________________________________________________________________________________________ __________________________________________________________________________________________________ To employee/obligor: If the employee/obligor has questions, contact _________________________________________ ______________ by phone at __________________, by fax____________________________, by email or website at __________________________________________________________________________________________________
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
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