Free Child Support – Order/Notice to Withhold Income (PDF) - Illinois

Dear Sir or Madam: If you are filing a Pro Se (without a lawyer) Petition to enforce a child support order, to establish child support, or to establish parentage in order to obtain child support, you may be entitled to the assistance of an attorney who represents the Illinois Department of Healthcare and Family Services and the Madison County State's Attorney's Office. You do NOT have to receive public assistance benefits to participate in this program. You may inquire about the Child Support Program by calling 1-800-447-4278 or by downloading the form at www.ilchildsupport.com and taking the form to the Belleville office. Depending on your income, there may be a one-time fee to participate in this program. The Judge is and remains impartial and cannot assist you with your pleadings or with presenting evidence. If you proceed without an attorney, please make sure you file adequate pleadings (especially if you are asking for contempt remedies), and that you are able to present evidence concerning income and failure to pay child support. If you are unable to present your evidence in the proper way, the Judge will not be able to award you the relief you are seeking. If you have already filed a pro se motion and wish to participate in this program rather than represent yourself, you can tell the Clerk and the other party in writing that you wish to wait to proceed until a later date when the State's Attorney can represent you. S/Thomas Chapman Hon. Thomas Chapman Presiding Judge, Family Division

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination County of Madison, State of Illinois Case Number:

Employer's/Withholder's Name Employer's/Withholder's Address Child(ren)'s Name(s): DOB:

Employer/Withholder's Federal EIN Number (if known) RE: Employee's/Obligor's Name: (Last, First, MI) Employee's/Obligor's Social Security Number Employee's/Obligor's Case Identifier Obligee Name (Last, First, MI) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available to the employee's/obligor's through his/her employment. . You are required by law to ORDER INFORMATION: This Order/Notice is based on the support order from Illinois deduct these amounts from the employee's/obligor's income until further notice. per current child support $ per past-due child support - Arrears 12 weeks or greater? yes no $ per current medical support $ $ per past-due medical support per spousal support $ $ per other (specify) per to be forwarded to the payee below. for a total of $ 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 bi-weekly pay period (every 2 weeks) $ per monthly pay period. $ REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the , begin withholding no later than the first pay period occurring employee's/obligor's principal place of employment is days after the date of . Send payment within working days of the pay date/date of withholding. % of the employee's/obligor's aggregate disposable weekly The total withheld amount, including your fee, cannot exceed earnings. , for limitations on withholding, applicable time If the employee's/obligor's principal place of employment is not requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's principal place of employment (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting by EFT/EDI, call Bank routing code: Make checks payable to: Authorized by Print Name and Title of Authorized Official(s)
IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.

before first submission. Use this FIPS code: 17119 ; ; Bank account number: . State Disbursement Unit Case #: Send check to: PO Box 5400 Payee and Case identifier Carol Stream, IL 60197 Date: Date:

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the State Child Support Enforcement Agency or party listed in number 12 below. Combining Payments: You can combine withheld amounts from more than one employee's/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/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The pay date/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (See #10 below). Termination Notification: You must promptly notify the Child Support Enforcement Agency or payee when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this order/notice to the Child Support Enforcement Agency or payee. CASE IDENTIFIER: EMPLOYEE'S/OBLIGOR'S NAME: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: Lump Sum Payments: You may be required to report and withhold from lump-sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump-sum payments, contact the person or authority below. Liability: If 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's/obligor's income and any other penalties set by State law.

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Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of child support withholding.

10.

Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. § 1673(b)); or 2) the amount allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions, and Medicare taxes. Additional Information:

11.

Submitted by:

12.

If you or your employee/obligor have any questions, contact: Child Support Section, Madison County Circuit Clerk, 155 N Main St, Edwardsville, IL 62025, by telephone (618) 692-6250 or by FAX (618) 692-8904. OMB: 0970-0154

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT Original Amended Termination 1a County of Madison, State of Illinois 1b/c 1d Case Number: 2a Employer's/Withholder's Name 2b Employer's/Withholder's Address 2c

SAMPLE WORKSHEET
Numbers at each entry correlate to numbered instructions on attached page

Child(ren)'s Name(s): 2d Employer/Withholder's Federal EIN Number (if known) RE: 3a Employee's/Obligor's Name: (Last, First, MI) 3b Employee's/Obligor's Social Security Number 3c Employee's/Obligor's Case Identifier 3d Obligee Name (Last, First, MI)

DOB:

If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available to the employee's/obligor's through his/her employment. . You are required by ORDER INFORMATION: This Order/Notice is based on the support order from 6 (State) law to deduct these amounts from the employee's/obligor's income until further notice. 7a per 7b current child support 14 $ 8a per 8b past-due child support - Arrears 12 weeks or greater? yes no $ 9a per 9b current medical support $ $ 10a per 10a past-due medical support 11a per 11b spousal support $ $ 12a per 12b other (specify) 12c for a total of $ 13a per 13b 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. $ 15c per semimonthly pay period (twice a month). $ 15a per bi-weekly pay period (every 2 weeks) $ 15d per monthly pay period. $ 15b REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the 16 , begin withholding no later than the first pay period occurring employee's/obligor's principal place of employment is 17 days after the date of 18. Send payment within 19 working days of the pay date/date of withholding. The total withheld amount, including your fee, cannot exceed 20 % of the employee's/obligor's aggregate disposable weekly earnings. If the employe's/obligor's principal place of employment is not 21 , 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 #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting by EFT/EDI, call Bank routing code: Make checks payable to: Authorized by 25a 22a 22c before first submission. Use this FIPS code: ; Bank account number: 22d Send check to: Date: Date: 24 25b 22b . ;

23 Payee and Case identifier

Print Name and Title 26 of Authorized Official(s)
IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is 27 different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the State Child Support Enforcement Agency or party listed in number 12 below. Combining Payments: You can combine withheld amounts from more than one employee's/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 Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. Employee/Obligor with Multiple Support Withholdings: If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (See #10 below). Termination Notification: You must promptly notify the Child Support Enforcement Agency or payee when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this order/notice to the Child Support Enforcement Agency or payee. CASE IDENTIFIER: EMPLOYEE'S/OBLIGOR'S NAME: DATE OF SEPARATION FROM EMPLOYMENT: LAST KNOWN HOME ADDRESS: NEW EMPLOYER/ADDRESS: Lump Sum Payments: You may be required to report and withhold from lump-sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump-sum payments, contact the person or authority below. Liability: If 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's/obligor's income and any other penalties set by State law. 28

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Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of child support withholding. 29

10.

Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (1 5 U.S.C. § 1673(b)); or 2) the amount allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions, and Medicare taxes. 30 Additional Information:

11.

Submitted by:

31

12.

If you or your employee/obligor have any questions, contact: Child Support Section, Madison County Circuit Clerk, 155 N Main St, Edwardsville, IL 62025, by telephone (618) 692-6250 or by FAX (618) 692-8904. OMB: 0970-0154

Instructions for Order/Notice to Withhold Income for Child Support The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. The following are instructions to complete the Order/Notice to withhold Income for Child Support. When completing the form, please include the following information. The person or agency completing this form may cross out the word "Order" or "Notice" if that term is inappropriate under the law of the issuing state. Item Description 1a. 1b. 1c. Check the appropriate status of the Order/Notice to withhold. Name of the issuing State or territory. Name of the order-issuing tribunal or other jurisdictional designation if any used by the orderissuing State. 1d. Identifying number used by the court/agency issuing this Order/Notice, if appropriate. 2a. Employer's/Withholder's name. 2b-c. Employer's/Withholder's mailing address, city and state. (This may differ from the Employer/Obligor work site.) 2d. Employer's/Withholder's nine-digit Federal employer identification numbers (if available). Include three-digit location code. 3a. 3b. 3c. 3d. 4. 5. Employee's/Obligor's last name, first name, and middle initial. Employee's/Obligor's Social Security Number (if known). Employee's/Obligor's Case Identifier Custodial Parent's last name, first name, and middle initial (if known). Child(ren)'s name(s) and date(s) of birth listed in the support order. Check if the child support order requires enrollment of the child(ren) in any health insurance coverage available to the employee's/obligor's through his/her employer. (The space on the form is provided for instructions to the employer, i.e. "see attached medical support form.")

ORDER INFORMATION: 6. 7a. 7b. 8a. 8b. 9a. 9b. 10a. 10b. Name of State that issued the order. Dollar amount to be withheld for payment of current child support. Time period that corresponds to the amount in #7a (such as month, week, etc.). Dollar amount to be withheld for payment of past-due child support under State law. Time period that corresponds to the amount in #8a (such as month, week, etc.). Dollar amount to be withheld for payment of current medical support, as appropriate, based on the underlying order. Time period that corresponds to the amount in #9a (such as month, week, etc.). Dollar amount to be withheld for payment of past-due medical support, if appropriate, based on the underlying order. Time period that corresponds to the amount in #10a (such as month, week, etc.).

Instructions to complete the Order/Notice to Withhold Income for Child Support - continued 11a. 11b. Dollar amount to be withheld for payment of past-due medical support, if appropriate, based on the underlying order. Time period that corresponds to the amount in #11a (such as month, week, etc.).

12a-c. Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order, time period that corresponds to the amount in #13a (e.g., month), and describe the miscellaneous obligation. 13a. 13b. 14. 15a. 15b. 15c. 15d. Total of #7a, 8a, 9a, 10a, 11a, and 12a. Time period that corresponds to the amount in #13a (e.g., month). Check if arrears are 12 weeks or greater. Amount an employer should withhold if the employee is paid weekly. Amount an employer should withhold if the employee is paid every two weeks. Amount an employer should withhold if the employee is paid twice a month. Amount an employer should withhold if the employee is paid once a month.

REMITTANCE INFORMATION: 16. 17. 18. 19. The State in which the Order/Notice is issued. Number of days in which the withholding must begin pursuant to the issuing state's law. The effective date of the income withholding. Number of working days within which an employer or other payor of income must remit amounts withheld pursuant to the issuing State's law. Maximum percentage that can be withheld based on the applicable withholding limit of the issuing State. If the Federal consumer Credit Protection Act laws of the issuing State allows the additional arrearage payment of 5 percentage points to the percentage normally specified in #20 (i.e., 65% of 60 or 55% instead of 50% if the obligor supports a second family), use this increased percentage in #20 and check #14 on the Order/Notice to indicate the support is 12 weeks or more in arrears. The State in which the this Order/Notice is issued. The agency's number for representative to provide EFT/EDI instructions. Contact the court/agency before the first EFT/EDI submission. Complete only for EFT/EDI transmission. Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters that identify the State and county. It is seven characters when it identifies the State, county, and a location within the county. It is necessary for centralized collections. Complete only for EFT/EDI transmission. Receiving agency's bank routing number. Complete only for EFT/EDI transmission. Receiving agency's bank account number.

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21. 22a.

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22c. 22d.

Instructions to complete the Order/Notice to Withhold Income for Child Support - continued 23. Name of collection unit (State Disbursement Unit), person, or tribunal/court specified in the underlying income withholding order to which payments are required to be sent. This form may not indicate a location other than that specified by an entity. Note: Payments will automatically be sent to State Disbursement Unit unless otherwise instructed. Street address, city and State of the collection unit, person, or tribunal/court identified in #22. This information is shared with the obligor. If you have a confidential address, please contact your IVD agency. Note: Payments will automatically be sent to State Disbursement Unit unless otherwise instructed. Enter your signature, or in the case of Public Aid recipients, signature of official(s) authorizing this Order/Notice. This line may be optional only if the Order/Notice includes the name and title of an official of the State or local IV-D agency on line 24, and a signature of the official is not required by State law. Date of signature. Print your name, or in cases of Public Aid recipients, the name and title of the official(s) of the State or local IV-D agency authorizing this Order/Notice. Check the box if the employer is to provide a copy of the Order/Notice to the employee. Penalty and/or citation for an employer who fails to comply with the Order/Notice. The State law governs unless the obligor is employed in another state, in which case the law of the state in which he or she is employed governs. Use this space to provide state-specific information. Penalty and/or citation for an employer who discharges, refuses to employ, or disciplines an employee/obligor as a result of the Order/Notice. The state law governs unless the obligor is employed in another state, in which case the law of the state in which he or she is employed governs. Use this space to provide state-specific information. Withholding limits enforced by the Federal Consumer Credit Protection Act (15 U.S.C.§ 1673(b)). Use this space to provide state-specific information on income withholding limits. Name and address of the state or local IV-D agency, tribunal/court, individual, or private agency submitting the income withholding. Name of child support enforcement agency's contact person or party whom an employer and/or employee/obligor may call for information regarding the Order/Notice. Telephone number of the contact person who an employer may call for information regarding the Order/Notice. Facsimile number for the person whom appears in #32a. Internet address for the person whose name appears in #32a.

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32a. 32b. 32c. 32d.

If the employer is a Federal government agency, the following instructions apply: Serve the Order/Notice upon the governmental agent listed in 5CFR part 581, appendix A. Sufficient identifying information must be provided in order for the obligor to be identified. It is, therefore, recommended that the following information, if known and if applicable, be provided: 1) full name of the obligor; 2) date of birth; 3) employment number, Department of Veterans Affairs claim number, or civil service retirement claim number; 4) component of the government entity for which the obligor works, and the official duty station or worksite; and 5) status of the obligor, e.g., employee, former employee, or annuitant. You may withhold from a variety of income and forms of payment, including voluntary separation incentive payments (buy-out payments), incentive pay, and cash awards. For a more complete list, see 5 CFR 581.103. ******************************** The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 45 CFR 303.7 of the child-support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.