***NOT FOR PUBLIC ACCESS***
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
City/County/Dist./Tribe
Private Individual/Entity
Remittance ID (include w/payment)
Order ID
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
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 biweekly pay period (every two weeks)
$
per semimonthly pay period (twice a month)
$
per monthly pay period
$
Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.