Employment Termination Notification Form

Employer’s Name:

Employee/Obligor’s Name:

CSE Agency Case Identifier:

Employer FEIN:

SSN:

Order Identifier:

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, you must promptly 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 questions, contact (Issuer name) by phone , by fax , 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 , by fax , by email or website at: .

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

Encryption Requirements:

When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Enforcement. Other electronic means, such as encrypted attachments to emails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).

The Paperwork Reduction Act of 1995

This information collection and associated responses are conducted in accordance with 45 CFR 303.100 of the Child Support Enforcement Program. This form is designed to provide uniformity and standardization. Public reporting for this collection of information is estimated to average two to five minutes per response. 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.