RE: Employee/Obligor's Name (Last, First, Ml) Custodial Party/Obligee's Name (Last, First, Ml) $ $

Transcription

1 tr tr EI INCOME WITHHOLDING FOR SUPPORT ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (lwo) tr AMENDED IWO ONE.TIME ORDER/NOTICE. LUMP SUM PAYMENT TERMINATION of IWO Date: tr Ct'ild Support Enforcement (CSE) Agency ECourt tr Attorney tr Private IndividuaUEntity (Check One) NOTE: lf you receive this document from someone other than a Slate or Tribal Child Support Enforcemont 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 jri attomey in thit State, or if under Tribal law a Tribal legal representative, may issue an income withholding order, the attomey or Tribai legal representative must include a copy of lhe State or Tribal law authorizing the attomey or Tribal legal representative to issue an income withholding order. Stateffribefferritory Texas Case ldentifier City/County/Dist.ff ribe Bell Order ldentifier Private Individual/Entity Employer/l ncome \Alithholdef s N ame Employer/lncom e \Alithholde/s Address RE: Employee/Obligor's Name (Last, First, Ml) Employee/Obligor's Social Security Number (if known) Custodial Party/Obligee's Name (Last, First, Ml) Employer/lncome \A/ithholder's Federal EIN Child's Name (Last, First, Ml) Child's Birth Date ORDER TNFORMATTON: 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. Month current child support past-due child support - Arears greater than 12 weeks? E Yes trno Month current cash medical support past-due cash medical support current spousal support past-due spousal support other (must speciff) for a total of $ per Month to be forwarded to the payee below. AMOUNTS TO WTTUHOLD:You do not have to vary your pay cycle to be in cornpliance with the Oder lnfomration. lf your pay cycle does not match the ordered payment cycle, Wthhold one of the follo\ ting amounts: E $ 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 lwo unless you receive a termination order. REMtTTANcElNFoRMA7'o'v. ftheemp oyee/ob igo,sprincipalp aceofemp oymentis@- you must begin withholding no later than the f rst pay period that occurs :q- days afrer the date of --. Si?i":-ymlnt wittrin 2 - working days of the pay date. lf you cannot withhold the full amount of support for any or all or<leri for this emptoyeelooliglor, wiurnoh up to S0.00 o16 of disposable income for all orders. lf the employee/obligofs_, _ principal place of em'ployment ij not Texas - -,,,,,., see the.addltlonal INFORMATION FOR Etr,tpioVens eno orhfn tucolue wthholders for limitrations withholding, applicable time requirements and any allo able employeis fees. Document Tracking ldentifier omb

2 For EFT/EDI instruc.tions, cor act the EFT/EDI office at the website listed belo,. lf paying by check, make check payablo to:. fncfude this Remittance ldentifierwlth payment:. Send check to: Texas Child Support Disbursement Unit P.O. Box San Antonio. TX 7826$9791 FIPS cod6 (lf necossary): - Signature (if required by State or Tribal law): Print Name: Title of lssuing Official: tr lf checked, you are required to provide a copy of this form to the emdoyee/obligor. lf the employee/obligor wod(s in a State or for a iribe lhat is difierent ftom the State or Tdbe that issued thi6 order, a copy must be provided to the employeer'obfigor wen if the box is not checked- ADDITIONAL I]{FORIIIATIOiI FOR EiiPLOYERS AND OTI{ER INCOTE WTTHHOLDERS State-specific infomation may be vi l/ved on the OCSE Employer Services website locat d at: yww.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts'htm priority: \,Vithholding for support has priority over any other legal process under State law (or Tribal lau, if applicable) against the same income. lf a Federal tax levy is in effect, please notify the contact person listed belor/. Comblnlng PaynrenE: You may combine withheld amounf fiom more than one employee/obligois income in a single paymento each agency/party requesting withholding. You must, holve\rer, separately iderfiry the portion of the single paymenthat is attdbutable to each employe /obligor. Roporting the Pay Date: You must reporthe pay dde when sending the payment. The pay date is the date on whicfi the ambunt was withhbb from the employee/obligois wages. You must comply wift the law of the S-tate (or Tribal law if applicable) of the employee/obligot's principal place of employment with respecto the time peliods within whicfi you must implement the withholding and fonard the support payments. Employee/Obligor lylth ilultiple Support Withholdln$: lf there is more than one Order/Noticegainsthis emiloyee,lo5tigor and you are unable to fully honor all support Orders/Notics due to federal, State, or Tribal withholding timits, you must fotlotv the Stiate or Tribal ladprocedure of the employee/obligot's principal place of employment. You.must honor ill OrdersNotices to the greatest extent possible, giving pdo{ity to cunent support before payment of any past-due support. Lump Sum Payments: You may be required to report and withhold fom lump sum payment such as bonuses, comririssions, or seveence pay. Contad the agency or peron listed belo\ t to determine if you are required to withhold or if you have any questions about lump sum payments. Liabitity: lf you have any doubts about the validity of the OrderNotice, contad the agency or pe6on listed belot\t. lf you fail to withliold income as tha Order/Notice direcls, ycu are liable for both the acs.rmulated amount you should have wilhheld tom the employe /obligot's income and any other penaltie set by State or Tribal lawprocedure. Antldbcdmlnauon: You are subjecl to a fine determined under State or Tribal law for discharging an emdoyee/obligor from employment. refuslnq to emolov, or takinq disciolinarv adion aqainst an erndlovee/obliqor becaus of a child suddort withholding. Wthholdlng Limib: You may not withhdd more than the lesser ofr 1) the amounts allofled by the Federal Comumer Credit proiedion Ad (ccpa) (15 U.S.C. 1673(b)); or2) the amount8 allc ^,ed by the state or Tribe of the emdoyee/obligot's principal place of emdoyment. Disposable income is the net income left after making mandatory dedlclions sucfi as: State, Fedeial, iocal taxes, Sdial Security tax6, statutory pension confibutions and Medicare taxes. The Federalimit is 500/6 of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting anothe{ family. Hdvever, that 50% limit is increas d to 55% and that 60% limit is increased to 65% if the anears ari greatdr than 'lz we*s. f permitted by the State, you may deducl a fee for administative cosls. The suppott amount and the fee may not exceed the limit indicated in this sec{ion' OMB Expiration Dale - 1Ol3'll2O1O. The OMB Expiration Date has no bearing on the termination date or validity ofthe income withholding odec it identifies the version of the form cunently in use.

3 Em ployee/obligot's Name: Order ldentifier: Case ldentifier: Employe/s Name: Arears greater than 12 weeks? lt the Oder tnfomation does not indicate whether the anears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lolfler percentage' For Tribal orders, you may not withhold more than the amounts allo red under the law of the issuing Tribe. For Tribal employers who reieive a State order, you may not withhold more than lhe lesser of the limit set by the law of the judsdiction in *triih the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C (b)' Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in det rmining disposable income and applying appropdate withholding limits. Additlonalnfo.rnatlon: NOT FICATION OF TERUINATION OF EiIPLOYUEI{T: You must promdly notify the Child Suppott Enfiorcenent agoncy and/or the person listed below by retuming this form to the con spondence address if: tr This person has never woiked for this emdoyer. tr This pason no longer works for this employer. Please provide the following iniormation ior the terminated employee: Termination date: Last known home address: Last known phone number: Date final payment made to the State Disbursement Unit or Tribal CSE agency: Final payment amount: New employe/s name: New employefs address: CONTACT INFORMATION To qmplover: lf the employer/income withholder has any questions, contact by phone at by fax at by or website at: Send terminatio notice and other correspondence to: To emlloyee/obllqor: lf the employee/obligor has questions, contact - --bv pttone at -, byfax- by orwebsite at IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.

4

5

6

7

8