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INCOME WITHHOLDING FOR SUPPORT ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION of IWO Date: Child Support Enforcement (CSE) Agency Court Attorney Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http://www.acf.hhs.gov/programs/cse/forms/OMB-0970-0154_instructions.pdf). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory Remittance Identifier (include w/payment) City/County/Dist./Tribe Order Identifier Private Individual/Entity CSE Agency Case Identifier Employer/Income Withholder’s Name Employer/Income Withholder’s Address Employee/Obligor’s Name (Last, First, Middle) Employee/Obligor’s Social Security Number Custodial Party/Obligee’s Name (Last, First, Middle) Employer/Income Withholder’s FEIN Child(ren)’s Name(s) (Last, First, Middle) Child(ren)’s Birth Date(s) RE: ORDER INFORMATION: This document is based on the support or withholding order from (State/Tribe). 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 Amount to Withhold of $ per . 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 pay period (twice a month) $ per biweekly pay period (every two weeks)$ per pay period $ 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 (State/Tribe), 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 (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB 0970-0154 Illinois 14 Mailing/Service 7 50 Illinois ---PAGE BREAK--- For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit [SDU]), see http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm. Include the Remittance Identifier with the payment and if necessary this FIPS code: . Remit payment to (SDU/Tribal Order Payee) at (SDU/Tribal Payee Address) Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: 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 of this IWO must be provided to the employee/obligor. If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at: http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the “Remit payment to” instructions on this form. 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 regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/ obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any 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 this IWO. OMB Expiration Date – 05/31/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. SIGN ---PAGE BREAK--- Employer’s Name: Employer FEIN: Employee/Obligor’s Name: CSE Agency Case Identifier: Order Identifier: 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 (see REMITTANCE INFORMATION). 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, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, an employer must notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: This person has never worked for this employer nor received periodic income. This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final payment date to SDU/ Tribal Payee: Final payment amount: New employer’s name: New employer’s address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact (Issuer name) by phone at , by fax at , by email or website at: . Send termination/income status notice and other correspondence to: (Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact (Issuer name) by phone at , by fax at , by email or website at . IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Allison & Mosby-Scott (309) 662-5084 (309) 662-2994 www.AllisonMosby-Scott.com Allison & Mosby-Scott, 210 North Williamsburg Drive, Bloomington Illinois 61704 Allison & Mosby-Scott (309) 662-5084 (309) 662-2994 www.AllisonMosby-Scott.com ---PAGE BREAK--- INCOME WITHOLDING FOR SUPPORT NOTICE REQUIREMENTS PURSUANT TO STATE LAW 750 ILCS 28/20(C) – http://www.ilga.gov/legislation/ilcs/documents/075000280K20.htm 1. Pursuant to 28/20(c)(1.1) this Income Withholding for Support is based upon a court order dated 2. Pursuant to 28/20(c)(5) the employer withholding fee shall not exceed $10 per month pursuant to state law 750 ILCS 28/35(a). 3. Pursuant to 28/20(c)(7) the duties of the employer/payor are defined pursuant to state laws 750 ILCS 32(a)3 – 40(d),(e)(g) and 28/35 in part as follows: It shall be the duty of any payor who has been served with an income withholding notice to deduct and pay over income as provided in this Section. The payor shall deduct the amount designated in the income withholding notice, as supplemented by any notice provided pursuant to subsection of Section 45, beginning no later than the next payment of income which is payable or creditable to the obligor that occurs 14 days following the date the income withholding notice was mailed, sent by facsimile or other electronic means, or placed for personal delivery to or service on the payor. The payor may combine all amounts withheld for the benefit of an obligee or public office into a single payment and transmit the payment with a listing of obligors form whom withholding has been effected. The payor shall pay the amount withheld to the State Disbursement Unit within 7 business days after the date the amount would (but for the duty to withhold income) have been paid or credited to the obligor. If the payor knowingly fails to withhold the amount designated in the income withholding notice or to pay any amount withheld to the State Disbursement Unit within 8 days after the date the amount would have been paid or credited to the obligor, then the payor shall pay a penalty of $100 for each day that the amount designated in the income withholding notice (whether or not withheld by the payor) is not paid to the State Disbursement Unit after the period of 7 business days has expired. The failure of a payor, on more than one occasion, to pay amounts withheld to the State Disbursement Unit within 7 business days after the date the amount would have been paid or credited to the obligor creates a presumption that the payor knowingly failed to pay over ---PAGE BREAK--- the amounts. This penalty may be collected in a civil action, which may be brought against the payor in favor of the obligee or public office. A finding of a payor’s nonperformance within the time required under this Act must be documented by a certified mail return receipt or a sheriff’s or private process server’s proof of service showing the date the income withholding notice was served on the payor. For purposes of this Act, a withheld amount shall be considered paid by a payor on the date it is mailed by the payor, or on the date an electronic funds transfer of the amount has been initiated by the payor or on the date delivery of the amount has been initiated by the payor. For each deduction, the payor shall provide the State Disbursement Unit at the time of transmittal, with the date the amount would (but for the duty to withhold income) have been paid or credited to the obligor. 4. Pursuant to 28/20(c)(7) the employer/payor is subject to fines and penalties as defined pursuant to state laws 750 ILCS 28/35 as stated above and 28/50 as follows: Where a payor willfully fails to withhold or pay over income pursuant to a properly served income notice, or willfully discharges, disciplines, refuses to hire or otherwise penalizes an obligor as prohibited by Section 40, or otherwise fails to comply with any duties imposed by this Act, the oblige, public office or obligor, as appropriate, may file a complaint with the court against the payor. The Clerk of the Circuit Court shall notify the obligee or public office, as appropriate, and the obligor and payor of the time and place of the hearing on the complaint. The court shall resolve any factual dispute including, but not limited to, a denial that the payor is paying or has paid income to the obligor. Upon a finding in favor of the complaining party, the court: shall enter judgment and direct the enforcement thereof for the total amount that the payor willfully failed to withhold or pay over; and may order employment or reinstatement of or restitution to the obligor, or both, where the obligor has been discharged, disciplined, denied employment or otherwise penalized by the payor and may impose a fine upon the payor not to exceed $200. Any obligee, public office or obligor who willfully initiates a false proceeding under this Act or who willfully fails to comply with the requirements of this Act shall be punished as in cases of contempt of court. Any officer or employee of any payor subject to the provisions of this Act who has the control, supervision, or responsibility for withholding and paying over income pursuant to an income ---PAGE BREAK--- withholding notice properly served on the payor and who willfully fails to withhold or pay over income as required under the income withholding notice shall be personally liable for a penalty equal to the total amount that was not withheld or paid over by the payor. Only where the employer has incurred sums due under this Section and is unable to pay such amounts may personal liability attach to a responsible officer or employee who has willfully failed to withhold and pay over income as required under the income withholding notice. The personal liability imposed by this subsection shall survive the dissolution of a partnership, limited liability company, or corporation. For the purposes of this subsection, “officer or employee of any payor” includes a partner of a partnership, a manager or member of a limited liability corporation, and a member of a registered limited liability partnership. 5. Pursuant to 28/20(c)(8) the rights, remedies and duties of the Obligor are defined by state laws 750 ILCS (28/20(b),(f),(g) – 28/25(b),(c) – 28/30(b),(c),(d) – 28/32(b),(c) – 28/35(a),(c),(d) – – – 28/50(a) – 28/55(c). 6. Pursuant to 28/20(c)(10) withholding for support shall terminate on which reflects the Order of Support referenced in paragraph 1 above. Prepared by: Attorney Name: Allison & Mosby-Scott Address: 210 North Williamsburg Drive Signature Bloomington Illinois Telephones: (309) 662-5084