Instruction for Completion of Withholding Form

The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. Submit the Order/Notice to employers in States that have adopted the Uniform Interstate Family Support Act (UIFSA) or have similar State laws.

The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information.

1a.	Name of your State or territory.
1b.	Name of your jurisdiction.
2.	Date the Order/Notice to Withhold is to be mailed.
3.	Identifying number used by the court/agency issuing this Order/Notice, if appropriate.
4a-c.	Check the appropriate case status of the Order/Notice to Withhold.
5.	Employer/Withholder's nine digit Federal employer identification number (if available). Include three digit location code (if known).
6a.	Employer/Withholder's name.
6b-e.	Employer/Withholder's mailing address. (This may differ from the Employee/Obligor work site.)
7.	Employee/Obligor's last name, first name, and middle initial (if known).
8.	Employee/Obligor's Social Security Number.
9.	Case identifier (or other identifier) used for recording the payment. (May be the same as #3.)
10.	Custodial Parent's last name, first name, and middle initial (if known).
11.	Child(ren)'s name(s) and date of birth listed in the support order.

Order Information:

12.	Name of State that issued the underlying child support order.
13.	Termination date of the support order.
14.	Check if the child support order requires enrollment of the child(ren) in any health insurance coverage available through the employee's/obligor's employment. If the obligor is a Federal government employee, please do not check the box provided. The space is provided for instructions, i.e. see attached form.
15a.	Dollar amount to be withheld for payment of current child support.
15b.	Time period that corresponds to the amount in #15a (e.g., month).
16a.	Dollar amount to be withheld for payment of past-due child support under your State law.
16b.	Time period that corresponds to the amount in #16a (e.g., month).
17a.	Dollar amount to be withheld for payment of medical support, as appropriate, based on the underlying order.
17b.	Time period that corresponds to the amount in #17a (e.g., month).
18a.	Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order.
18b.	Time period that corresponds to the amount in #18a (e.g., month).
18c.	Describe the amount(s) represented in #18a separately by fee type (e.g., court fees).
19a.	Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order and time period that corresponds to the amount in #19a (e.g., month).
19b.	Time period that corresponds to the amount in #19a (e.g., month).
19c.	Describe the amount(s) represented in #19a separately by fee type (e.g., court fees).
20a.	Total of #15a, #16a, #17a, #18a, and #19a.
20b.	Time period that corresponds to the amount in #15b (e.g., month).
21.	Check this box if arrears are 12 weeks or greater.
22a.	Amount an employer withholds if the employee is paid weekly.
22b.	Amount an employer withholds if the employee is paid every two weeks.
22c.	Amount an employer withholds if the employee is paid twice a month
22d.	Amount an employer withholds if the employee once a month.

Remittance Information:

23.	Number of days in which the withholding must begin pursuant to the law of your State.
24.	Number of working days an employer or other payor of income must remit amounts withheld pursuant to the law of your State.
25.	Amount or percentage that an employer or other payor of income may deduct in addition to child support from its payment as a fee for withholding child support pursuant to the law of your State. If your State does not permit deduction of a fee, enter 0. Employers with employees/obligors located in another State should know those State laws.
26.	Maximum percentage that can be withheld based on the applicable withholding limit of your State. If the employer is a Federal agency and you add the additional 5 percentage points allowed under the Federal Consumer Credit Protection Act to the percentage entered for #22 (i.e., 65%; or 55% instead of 50% if the obligor supports a second family), check #14c on the Order/Notice to indicate the support is 12 weeks or more in arrears.
27a.	Case identifier or other identifier. (May be the same as #3 and/or #9.)
27b.	Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters that identifies 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.
27c.	Receiving agency's bank routing number. Complete only for EFT/EDI transmission.
27d.	Receiving agency's bank account number. Complete only for EFT/EDI transmission.
28a.	Name of the child support enforcement agency to which payments are made and the case identifier on the payment line.
28b-d.	Street address, City, and State of the child support enforcement agency identified in #28a.
29a.	Signature of official(s) authorized to send the Order/Notice. This line is optional if a signature is not required by State statute.
29b.	Print name of the official(s) authorized to send the Order/Notice.
30.	Check the box if the employer is to provide a copy of the Order/Notice to the employee.
31.	Penalty and your State citation for an employer who fails to comply with the Order/Notice. Your 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.
32.	Penalty and your State citation for an employer who discharges, refuses to employ, or disciplines an employee/obligor as a result of the Order/Notice. Your 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.
33.	Use this space to provide the employer with additional information.
34a.	Name of the agency or court requesting the income withholding.
34b-e.	Address of the agency or court requesting the income withholding.
35a.	Name of the child support enforcement agency's contact person who an employer and/or employee/obligor may call for information regarding the Order/Notice.
35b.	Telephone number of the contact person who an employer may call for information regarding the Order/Notice.
35c.	Facsimile number for the person whose name appears in #35a.
35d.	Internet address for the person whose name appears in 35a.

If the employer is a Federal Government agency the following instructions apply.

• Serve the Order/Notice upon the governmental agent listed in 5 CFR 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 (buyout 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.