Fillable Order/notice To Withhold Income For Child Support printable pdf download

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

NOTICE OF AN ORDER TO WITHHOLD INCOME FOR CHILD SUPPORT

Original

Amended

Termination

Date:

State/Tribe/Territory

City/Co./Dist./Reservation

Non-governmental entity or Individual

Case Number

RE:

Employer’s/Withholder's Name

Employee’s/Obligor’s Name (Last, First, MI)

Employer’s/Withholder's Address

Employee’s/Obligor’s Social Security Number

Employee’s/Obligor’s Case Identifier

Employer’s/Withholder's Federal EIN Number (if known)

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’s/obligor’s income until further notice.

Per

current child support

Per

past-due child support - Arrears greater than12 weeks?

yes

Per

current cash medical support

Per

past-due cash medical support

Per

spousal support

Per

past-due spousal support

Per

other (specify)

for a total of $

per

to be forwarded to the payee below.

You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the

ordered payment cycle, withhold one of the following amounts:

per weekly pay period.

per semimonthly pay period (twice a month).

per biweekly pay period (every two weeks).$

per monthly pay period.

REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If

the employee’s/obligor’s principal place of employment is

in the State of Alabama

, begin withholding no

later than the first pay period occurring

days after the date of

. Send payment within seven (7) working days of

the pay date/date of withholding. The total withheld amount, including your fee, may not exceed

% of the

employee's/obligor's aggregate disposable weekly earnings.

If the employee’s/obligor’s principal place of employment is not in the State of Alabama

, for limitations on

withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the

employee’s/obligor’s principal place of employment (see #3 and #9, ADDITIONAL INFORMATION TO EMPLOYERS AND

OTHER WITHHOLDERS).

Make check payable to: Alabama Child Support Payment Center (ACSPC)

Send check to: P. O. Box 244015, Montgomery, AL 36124-4015

If remitting payment by EFT/EDI, call 1-866-252-4453 before first submission. Use this FIPS code:

Bank routing number:

Bank account number:

If this is an Order/Notice to Withhold:

If this is a Notice of an Order to Withhold:

Print Name

Title of Issuing Official

Title (if appropriate)

Signature and Date

IV-D

Agency

Court

Attorney

Individual

Private Entity

Attorney with authority under state law to issue order/notice.

NOTE: Non-IV-D Attorneys, individuals, and non-governmental entities must submit a Notice of an Order to Withhold and

include a copy of the income withholding order unless, under a state’s law, an attorney in that state may issue an income

withholding order. In that case, the attorney may submit an Order/Notice to Withhold and include a copy of the state law

authorizing the attorney to issue an income withholding order/notice.

IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.

OMB 0970-0154

Order/notice To Withhold Income For Child Support

Related Articles

Related forms

Related Categories