NOTE TO EMPLOYER/INCOME WITHHOLDER:

The employer/income withholder may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act [15USC §1673(b)]; or 2) the amounts allowed by the jurisdiction of the employee/obligor’s principal place of employment (i.e., the amounts allowed by state law if the employee/obligor’s principal place of employment is in a state; or the amounts allowed by tribal law if the employee/obligors principal place of employment is under tribal jurisdiction). State-specific withholding limitations, time requirements, and any allowable employee fees are available at www.acf.hhs.gov/css/resource/state-income-withholding-contracts-and-program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please contact the tribe at www.acf.hhs.gov/sites/default/files/programs/css/tribal agency contacts printable pdf.pdf or https://www.bia.gov/tribalmap/DataDotGovSamples/tld map.html.

A federal government agency may withhold from a variety of incomes 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.

COMPLETED BY SENDER:

21.
State/Tribe. Name of the state or tribe sending this document.
22.
Locator Code. Geographic Locator Codes are standard codes for states, counties, and cities issued by the National Institute of Standards and Technology. These were formerly known as Federal Information Processing Standards (FIPS) codes.
23.
SDU/Tribal Order Payee. Name of SDU (or payee specified in the underlying tribal support order) to which payments must be sent.
24.
SDU/Tribal Payee Address. Address of the SDU (or payee specified in the underlying tribal support order) to which payments must be sent.

COMPLETED BY EMPLOYER/INCOME WITHHOLDER:

25.
Return to Sender Checkbox. The employer/income withholder should check this box and return the IWO to the sender if this IWO is not payable to an SDU or Tribal Payee or this IWO is not regular on its face as indicated on page 1 of these instructions.

COMPLETED BY SENDER IF REQUIRED BY STATE OR TRIBAL LAW:

26.
Signature of Judge/Issuing Official. Signature of the official authorizing this IWO.
27.
Print Name of Judge/Issuing Official. Name of the official authorizing this IWO.
28.
Title of Judge/Issuing Official. Title of the official authorizing this IWO.
29.
Date of Signature. Date the judge/issuing official signs this IWO.
30.
Copy of IWO checkbox. Check this box for all intergovernmental IWOs. If checked, the employer/income withholder is required to provide a copy of the IWO to the employee/obligor.

ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS

The following fields refer to federal, state, or tribal laws that apply to issuing an IWO to an employer/income withholder. State- or tribal-specific information may be included only in the fields below.

INCOME WITHHOLDING FOR SUPPORT – Instructions/INTA0021 OMB 0970-0154 Expiration Date: 08/31/2020 Page 5 of 7