Preview
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
233-623981-17
FILED
INCOME WITHHOLDING FOR SUPPORT TARRANT COUNTY
10/15/2020 9:34 PM
THOMAS A. WILDER
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) DISTRICT CLERK
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION OF IWO Date: 10/14/2020
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 TEXAS Remittance ID (include w/payment)
City/County/Dist./Tribe Tarrant Order ID 233-623981-17
Private Individual/Entity CSE Agency Case ID
Izzy's Nursery Inc RE: Palominos, Ismael O.
Employer/Income Withholder's Name Employee/Obligor's Name (Last, First, Middle)
PO Box 97
Employer/Income Withholder's Address Employee/Obligor's Social Security Number
Banks, OR 97106 Palominos, Sonia
Custodial Party/Obligee’s Name (Last, First, Middle)
Employer/Income Withholder's FEIN
Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s)
Palominos, Alexa N. 08/25/2015
ORDER INFORMATION: This document is based on the support or withholding order from TEXAS
(State/Tribe). You are required by law to deduct these amounts from the employee/obligor's income until further notice.
$ 351.86 Per Month current child support
$ 0.00 Per N/A past-due child support - Arrears greater than 12 weeks? Yes No
$ 145.00 Per N/A current cash medical support
$ 0.00 Per N/A past-due cash medical support
$ 0.00 Per N/A current spousal support
$ 0.00 Per N/A past-due spousal support
$ 0.00 Per N/A other (must specify) .
for a Total Amount to Withhold of $ 496.86 per Month .
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:
$ 114.66 per weekly pay period $ 248.43 per semimonthly pay period (twice a month)
$ 229.32 per biweekly pay period (every two weeks)$ 496.86 per monthly pay period
$ $ 0.00 Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
Document Tracking ID OMB 0970-0154
1
Employer's Name: Izzy's Nursery Inc Employer FEIN:
Employee/Obligor's Name: Palominos, Ismael O. SSN:
CSE Agency Case Identifier: Order Identifier: 233-623981-17
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is TEXAS
(State/Tribe), you must begin withholding no later than the first pay period that occurs 0 days after the date
of delivery . Send payment within 2 working days of the pay date. If you cannot withhold the full amount of support
for any or all orders for this employee/obligor, withhold up to 50 % of disposable income. If the obligor is a non-
employee, obtain withholding limits from Supplemental Information on page 3. If the employee/obligor's principal place of
employment is not TEXAS (State/Tribe), obtain withholding limitations, time requirements,
and any allowable employer fees at www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-
program-information for the employee/obligor's principal place of employment.
For electronic payment requirements and centralized payment collection and disbursement facility information (State
Disbursement Unit (SDU)), see www.acf.hhs.gov/programs/css/employers/electronic-payments.
Include the Remittance ID with the payment and if necessary this FIPS code: 48000 .
Remit payment to Texas Child Support Disbursement Unit (SDU/Tribal Order Payee)
at P.O. Box 659791, San Antonio, TX 78265-9791 (SDU/Tribal Payee Address)
Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed
to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender.
Signature of Judge/Issuing Official (if Required by State or Tribal Law):
Print Name of Judge/Issuing Official: Judge Kenneth E. Newell. / Assoc Judge Kate Stone
Title of Judge/Issuing Official: District Judge / Assoc Judge
Date of Signature:
If the employee/obligor works in a state or for a tribe that is different from the state or tribe that issued this order, a copy of
this IWO must be provided to the employee/obligor.
If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
State-specific contact and withholding information can be found on the Federal Employer Services website located at
www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-information.
Priority: Withholding for support has priority over any other legal process under State law against the same income (42
USC §666(b)(7)). If a federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or tribal CSE agency, you may combine withheld amounts
from more than one employee/obligor's income in a single payment. You must, however, separately identify each
employee/obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the
custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this
IWO was sent by a court, attorney, or private individual/entity and the initial order was entered before January 1, 1994 or
the order was issued by a tribal CSE agency, you must follow the “Remit payment to” instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the state (or tribal law if
applicable) of the employee/obligor's principal place of employment regarding time periods within which you must
implement the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs
due to federal, state, or tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to
current support before payment of any past-due support. Follow the state or tribal law/procedure of the employee/obligor's
principal place of employment to determine the appropriate allocation method.
OMB Expiration Date - 7/31/2017. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the
version of the form currently in use. 2
Employer's Name: Izzy's Nursery Inc Employer FEIN:
Employee/Obligor's Name: Palominos, Ismael O. SSN:
CSE Agency Case Identifier: Order Identifier: 233-623981-17
Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to
this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are
required to report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld
and any penalties set by state or tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor
from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer
Credit Protection Act (CCPA) (15 USC §1673(b)); or 2) the amounts allowed by the state of the employee/obligor's
principal place of employment or tribal law if a tribal order (see Remittance Information). Disposable income is the net
income after mandatory deductions such as: state, federal, local taxes; Social Security taxes; statutory pension
contributions; and Medicare taxes. The federal limit is 50% of the disposable income if the obligor is supporting another
family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase
5% --to 55% and 65% --if the arrears are greater than 12 weeks. If permitted by the state or tribe, you may deduct a fee
for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section.
For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal
employers/income withholders who receive a state IWO, you may not withhold more than the limit set by tribal law.
Depending upon applicable state or tribal law, you may need to consider amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks,
then the employer should calculate the CCPA limit using the lower percentage.
Supplemental Information:
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
3
Employer's Name: Izzy's Nursery Inc Employer FEIN:
Employee/Obligor's Name: Palominos, Ismael O. SSN:
CSE Agency Case Identifier: Order Identifier: 233-623981-17
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 e-mail or website: .
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 e-mail or website: .
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 burden for this collection of information is
estimated to average 5 minutes per response for Non-IV-D CPs; 2 minutes per response for employers; 3 seconds for e-IWO employers,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
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.
4
Preview
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA 233-623981-17 FILED INCOME WITHHOLDING FOR SUPPORT TARRANT COUNTY 10/15/2020 9:34 PM THOMAS A. WILDER ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) DISTRICT CLERK AMENDED IWO ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO Date: 10/14/2020 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 TEXAS Remittance ID (include w/payment) City/County/Dist./Tribe Tarrant Order ID 233-623981-17 Private Individual/Entity CSE Agency Case ID Izzy's Nursery Inc RE: Palominos, Ismael O. Employer/Income Withholder's Name Employee/Obligor's Name (Last, First, Middle) PO Box 97 Employer/Income Withholder's Address Employee/Obligor's Social Security Number Banks, OR 97106 Palominos, Sonia Custodial Party/Obligee’s Name (Last, First, Middle) Employer/Income Withholder's FEIN Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) Palominos, Alexa N. 08/25/2015 ORDER INFORMATION: This document is based on the support or withholding order from TEXAS (State/Tribe). You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ 351.86 Per Month current child support $ 0.00 Per N/A past-due child support - Arrears greater than 12 weeks? Yes No $ 145.00 Per N/A current cash medical support $ 0.00 Per N/A past-due cash medical support $ 0.00 Per N/A current spousal support $ 0.00 Per N/A past-due spousal support $ 0.00 Per N/A other (must specify) . for a Total Amount to Withhold of $ 496.86 per Month . 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: $ 114.66 per weekly pay period $ 248.43 per semimonthly pay period (twice a month) $ 229.32 per biweekly pay period (every two weeks)$ 496.86 per monthly pay period $ $ 0.00 Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. Document Tracking ID OMB 0970-0154 1 Employer's Name: Izzy's Nursery Inc Employer FEIN: Employee/Obligor's Name: Palominos, Ismael O. SSN: CSE Agency Case Identifier: Order Identifier: 233-623981-17 REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is TEXAS (State/Tribe), you must begin withholding no later than the first pay period that occurs 0 days after the date of delivery . Send payment within 2 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 50 % of disposable income. If the obligor is a non- employee, obtain withholding limits from Supplemental Information on page 3. If the employee/obligor's principal place of employment is not TEXAS (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and- program-information for the employee/obligor's principal place of employment. For electronic payment requirements and centralized payment collection and disbursement facility information (State Disbursement Unit (SDU)), see www.acf.hhs.gov/programs/css/employers/electronic-payments. Include the Remittance ID with the payment and if necessary this FIPS code: 48000 . Remit payment to Texas Child Support Disbursement Unit (SDU/Tribal Order Payee) at P.O. Box 659791, San Antonio, TX 78265-9791 (SDU/Tribal Payee Address) Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if Required by State or Tribal Law): Print Name of Judge/Issuing Official: Judge Kenneth E. Newell. / Assoc Judge Kate Stone Title of Judge/Issuing Official: District Judge / Assoc Judge Date of Signature: If the employee/obligor works in a state or for a tribe that is different from the state or tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS State-specific contact and withholding information can be found on the Federal Employer Services website located at www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-information. Priority: Withholding for support has priority over any other legal process under State law against the same income (42 USC §666(b)(7)). If a federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a court, attorney, or private individual/entity and the initial order was entered before January 1, 1994 or the order was issued by a tribal CSE agency, you must follow the “Remit payment to” instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the state (or tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to federal, state, or tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the state or tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. OMB Expiration Date - 7/31/2017. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. 2 Employer's Name: Izzy's Nursery Inc Employer FEIN: Employee/Obligor's Name: Palominos, Ismael O. SSN: CSE Agency Case Identifier: Order Identifier: 233-623981-17 Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by state or tribal law/procedure. Anti-discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 USC §1673(b)); or 2) the amounts allowed by the state of the employee/obligor's principal place of employment or tribal law if a tribal order (see Remittance Information). Disposable income is the net income after mandatory deductions such as: state, federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% --to 55% and 65% --if the arrears are greater than 12 weeks. If permitted by the state or tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers/income withholders who receive a state IWO, you may not withhold more than the limit set by tribal law. Depending upon applicable state or tribal law, you may need to consider amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. Supplemental Information: IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. 3 Employer's Name: Izzy's Nursery Inc Employer FEIN: Employee/Obligor's Name: Palominos, Ismael O. SSN: CSE Agency Case Identifier: Order Identifier: 233-623981-17 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 e-mail or website: . 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 e-mail or website: . 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 burden for this collection of information is estimated to average 5 minutes per response for Non-IV-D CPs; 2 minutes per response for employers; 3 seconds for e-IWO employers, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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. 4