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 www.acf.hhs.gov/programs/css/resource/income-withholding-for-support-instructions). 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 Indiana

Remittance ID (include w/payment)

City/County/Dist./Tribe

Order ID

Private Individual/Entity

CSE Agency Case ID

Employer/Income Withholder’s Name

Employer/Income Withholder’s Address

Employer/Income Withholder’s FEIN:

Child(ren)’s Name(s) (First, M, Last) Child(ren)’s Birth Date(s)

RE:

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

Employee/Obligor’s Social Security Number

**last 4 digits only** XXX-XX-

Employee/Obligor’s Date of Birth

Custodial

Party/Obligee’s Name (First, M, Last)

ORDER INFORMATION:

This document is based on the support or withholding order from Indiana (State/Tribe). You are required by law to deduct these amounts from the employee/obligor’s income until further notice.

current child support

past-due child support - Arrears greater than 12 weeks? () Yes () No

current cash medical support

past-due cash medical support

current spousal support

past-due spousal support

other (must specify)

for a Total Amount to Withhold of $ .

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 semimonthly pay period (twice a month)

$ per biweekly pay period (every two weeks)

$ per monthly pay period

$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.