Preview
INCOME WITHHOLDING FOR SUPPORT
D INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
IB] AMENDED IWO
D ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
O TERMINATION OF IWO Date: June 11 2018
D Child Support Enforcement (CSE) Agency D Court IB] Attorney D 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.act,hhs.gov/css/resource/income-withholdinq-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 support order must be
attached.
State/Tribe/TerritoryT Le~x~a~s_ _ _ _ _ _ _ _ _ Remittance ID (include w/payment) _ _ _ _ _ _ _ _ _ __
City/County/Dist/Tribe Fort Worth/Tarrant Order ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Private Individual/Entity Case ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
CVS Health Department 99431 RE:LE LOC
Employer/Income Withholder's Name Employee/Obligor's Name (Last, First, Middle)
I cys Drive Woonsocket RI 02895 XXX-XX-X281
Employer/Income Withholder's Address Employee/Obligor's Social Security Number
Employee/Obligor's Date of Birth
THAI TUYETTRINH
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)
LE, CHARLIZE 03/31/2015
ORDER INFORMATION: This document is based on the support order from Texas (State/Tribe).
You are required by law to deduct these amounts from the employee/obligor's income until further notice.
$ I 298oo Per month current child support
$ Per past-due child support-Arrears greater than 12 weeks? D Yes D No
$ Per current cash medical support
$ Per past-due cash medical support
$ Per current spousal support
$ Per past-due spousal support
$ Per other (must specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
for a Total Amount to Withhold of$ 1 298.00 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:
$ 299 54 per weekly pay period $ 649 oo per semimonthly pay period (twice a month)
$ 599 08 per biweekly pay period (every two weeks)$ J 298 00 per monthly pay period
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
Document Tracking ID 2~3~3~-6~1~2~88~7~-Ll7 ~ - - - - - - - -
Income \Mthholding for Support (IWO) OMB 0970-0154 Ex~ration Date: 08/31/2020 Page 1 of 4
Employer's Name:cys Health Departr~943 l Employer FEIN:
-------
E,mployee/Obligor's Name:L~E=L~O=C~---------------- SSN: XXX-XX-X281
Case Identifier: Order Identifier:
-------------~ --------------------
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is-T-e-x-as~--------
(State/Tribe), you must begin withholding no later than the first pay period that occurs ___5_ days after the date
of the order . Send payment within ___2_ business days of the pay date. If you cannot withhold the full amount of
support for any or all orders for this employee/obligor, withhold _5_Q__ % of disposable income for all orders. If the obligor is
a non-employee, obtain withholding limits from Supplemental Information. If the employee/obligor's principal place of
employment is notTexas (State/Tribe), obtain withholding limitations, time requirements,
and any allowable employer fees from the jurisdiction of the employee/obligor's principal place of employment. State-
specfic withholding limit information is available at www.acf.hhs.gov/css/resource/state-income-withholdinq-contacts-and-
program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please contact the
tribe at www.acf.hhs.gov/sites/default/files/proqrams/css/tribal agency contacts printable pdf.pdf or
https://www.bia.gov/tribalmap/DataDotGovSamples/tld map.html.
For electronic payment requirements and centralized payment collection and disbursement facility information [State
Disbursement Unit (SOU)], see www.acf.hhs.gov/css/employers/employer-responsibilities/payments.
Include the Remittance ID with the payment and if necessary this locator code:
Remit payment to Texas State Disbursement Unit (SDU) (SOU/Tribal Order Payee)
at P.O. Box 659791 San Antonio Texas 78265-9791 (SOU/Tribal Payee Address)
D Return to Sender (Completed by Employer/lncom
accordance with sections 466(b)(S) and (6) oft Social
payment is not directed to an SOU/Tribal Pay e or this I
the IWO to the sender.
If Required by State or Tribal Law:
Signature of Judge/Issuing Official: c - - - - + - f f f - - ' J h - - - - , - - , - - - - - - - - - - - - - - - - - - - - - -
Print Name of Judge/Issuing Official: -----1~,:F'_=-f':::==---,'-l-('-'.-,.':-rr:..:....c5"--------------------
Title of Judge/Issuing Official: -----~,d>~"'Jl--1Lii.1"=---.i..>!.v:e:,,('-¥'.'::.._------------------
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.
Olf checked, the employer/income withholder must provide a copy of this form to the employee/obliger.
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/css/resource/state-income-withholding-contacts-and-program-requirements.
Employers/income withholders may use OCSE's Child Support Portal (https://ocsp.acf.hhs.gov/csp/) to provide
information about employees who are eligible to receive a lump sum payment, have terminated employment, and to
provide contacts, addresses, and other information about their company.
Priority: Withholding for support has priority over any other legal process under State law against the same income
(section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SOU 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/obliger's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate sou or to a
tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an sou (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.
Income Withholding for Support (IWO) Page 2 of 4
Employer's Name: CVS Health Departrm::::::99431 Employer FEIN:
E~ployee/Obligor's Name: LecE'4-JL..,.,,.C~---------------- SSN:xxX-XX-X281
Case Identifier:
- - - - - - - - - - - - - ~ Order Identifier:
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/obliger's wages. You must comply with the law of the state (or tribal law if
applicable) of the employee/obliger'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/obliger and you are unable to fully honor all IWOs
due to federal, state, or tribal withholding limits, you must honor all lWOs 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/obliger's
principal place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to
this employee/obliger such as bonuses, commissions, or severance pay. Contact the sender to detemiine 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/obliger'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/obliger
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 law of the state of the employee/
obliger's principal place of employment, if the place of employment is in a state; or the tribal law of the employee/obliger's
principal place of employment if the place of employment is under tribal jurisdiction. 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 obliger is supporting another
family and 60% of the disposable income if the obliger is not supporting another family. However, those limits increase
5% -to 55% and 65% --if the arrears are greater than 12 weeks. If pemiitted 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.
Depending upon applicable state or tribal law, you may need to consider amounts paid for health care premiums in
detemiining disposable income and applying appropriate withholding limits.
Arrears Greater Than 12 Weeks? If the Order Information section 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:
Income Withholding for Support (IWO) Page 3 of 4
Employer's Name: CVS Health Depart~9431 Employer FEIN: _ _ _ _ _ __
E[Tiployee/Obligor's Name:L~E,__L~O=~---------------- SSN:XXX-XX-X281
Case Identifier: _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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:
D This person has never worked for this employer nor received periodic income.
D 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 telephone number: _ _ _ _ _ _ __
----------------
Last known address:
Final payment date to SOU/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 telephone: _ _ _ _ _ _ _ , by fax: _ _ _ _ _ _ _ • by email 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 telephone: _ _ _ _ _ _ _ . by fax: _ _ _ _ _ _ _ , by email or website: _ _ _ _ _ _ _ _ _ _ _ _ __
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.
Income \Mthholding for Support (IWO) Page 4 of 4
Preview
INCOME WITHHOLDING FOR SUPPORT D INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) IB] AMENDED IWO D ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT O TERMINATION OF IWO Date: June 11 2018 D Child Support Enforcement (CSE) Agency D Court IB] Attorney D 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.act,hhs.gov/css/resource/income-withholdinq-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 support order must be attached. State/Tribe/TerritoryT Le~x~a~s_ _ _ _ _ _ _ _ _ Remittance ID (include w/payment) _ _ _ _ _ _ _ _ _ __ City/County/Dist/Tribe Fort Worth/Tarrant Order ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Private Individual/Entity Case ID _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ CVS Health Department 99431 RE:LE LOC Employer/Income Withholder's Name Employee/Obligor's Name (Last, First, Middle) I cys Drive Woonsocket RI 02895 XXX-XX-X281 Employer/Income Withholder's Address Employee/Obligor's Social Security Number Employee/Obligor's Date of Birth THAI TUYETTRINH 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) LE, CHARLIZE 03/31/2015 ORDER INFORMATION: This document is based on the support order from Texas (State/Tribe). You are required by law to deduct these amounts from the employee/obligor's income until further notice. $ I 298oo Per month current child support $ Per past-due child support-Arrears greater than 12 weeks? D Yes D No $ Per current cash medical support $ Per past-due cash medical support $ Per current spousal support $ Per past-due spousal support $ Per other (must specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ for a Total Amount to Withhold of$ 1 298.00 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: $ 299 54 per weekly pay period $ 649 oo per semimonthly pay period (twice a month) $ 599 08 per biweekly pay period (every two weeks)$ J 298 00 per monthly pay period $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. Document Tracking ID 2~3~3~-6~1~2~88~7~-Ll7 ~ - - - - - - - - Income \Mthholding for Support (IWO) OMB 0970-0154 Ex~ration Date: 08/31/2020 Page 1 of 4 Employer's Name:cys Health Departr~943 l Employer FEIN: ------- E,mployee/Obligor's Name:L~E=L~O=C~---------------- SSN: XXX-XX-X281 Case Identifier: Order Identifier: -------------~ -------------------- REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is-T-e-x-as~-------- (State/Tribe), you must begin withholding no later than the first pay period that occurs ___5_ days after the date of the order . Send payment within ___2_ business days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold _5_Q__ % of disposable income for all orders. If the obligor is a non-employee, obtain withholding limits from Supplemental Information. If the employee/obligor's principal place of employment is notTexas (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees from the jurisdiction of the employee/obligor's principal place of employment. State- specfic withholding limit information is available at www.acf.hhs.gov/css/resource/state-income-withholdinq-contacts-and- program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please contact the tribe at www.acf.hhs.gov/sites/default/files/proqrams/css/tribal agency contacts printable pdf.pdf or https://www.bia.gov/tribalmap/DataDotGovSamples/tld map.html. For electronic payment requirements and centralized payment collection and disbursement facility information [State Disbursement Unit (SOU)], see www.acf.hhs.gov/css/employers/employer-responsibilities/payments. Include the Remittance ID with the payment and if necessary this locator code: Remit payment to Texas State Disbursement Unit (SDU) (SOU/Tribal Order Payee) at P.O. Box 659791 San Antonio Texas 78265-9791 (SOU/Tribal Payee Address) D Return to Sender (Completed by Employer/lncom accordance with sections 466(b)(S) and (6) oft Social payment is not directed to an SOU/Tribal Pay e or this I the IWO to the sender. If Required by State or Tribal Law: Signature of Judge/Issuing Official: c - - - - + - f f f - - ' J h - - - - , - - , - - - - - - - - - - - - - - - - - - - - - - Print Name of Judge/Issuing Official: -----1~,:F'_=-f':::==---,'-l-('-'.-,.':-rr:..:....c5"-------------------- Title of Judge/Issuing Official: -----~,d>~"'Jl--1Lii.1"=---.i..>!.v:e:,,('-¥'.'::.._------------------ 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. Olf checked, the employer/income withholder must provide a copy of this form to the employee/obliger. 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/css/resource/state-income-withholding-contacts-and-program-requirements. Employers/income withholders may use OCSE's Child Support Portal (https://ocsp.acf.hhs.gov/csp/) to provide information about employees who are eligible to receive a lump sum payment, have terminated employment, and to provide contacts, addresses, and other information about their company. Priority: Withholding for support has priority over any other legal process under State law against the same income (section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SOU 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/obliger's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate sou or to a tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an sou (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. Income Withholding for Support (IWO) Page 2 of 4 Employer's Name: CVS Health Departrm::::::99431 Employer FEIN: E~ployee/Obligor's Name: LecE'4-JL..,.,,.C~---------------- SSN:xxX-XX-X281 Case Identifier: - - - - - - - - - - - - - ~ Order Identifier: 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/obliger's wages. You must comply with the law of the state (or tribal law if applicable) of the employee/obliger'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/obliger and you are unable to fully honor all IWOs due to federal, state, or tribal withholding limits, you must honor all lWOs 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/obliger's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to this employee/obliger such as bonuses, commissions, or severance pay. Contact the sender to detemiine 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/obliger'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/obliger 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 law of the state of the employee/ obliger's principal place of employment, if the place of employment is in a state; or the tribal law of the employee/obliger's principal place of employment if the place of employment is under tribal jurisdiction. 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 obliger is supporting another family and 60% of the disposable income if the obliger is not supporting another family. However, those limits increase 5% -to 55% and 65% --if the arrears are greater than 12 weeks. If pemiitted 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. Depending upon applicable state or tribal law, you may need to consider amounts paid for health care premiums in detemiining disposable income and applying appropriate withholding limits. Arrears Greater Than 12 Weeks? If the Order Information section 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: Income Withholding for Support (IWO) Page 3 of 4 Employer's Name: CVS Health Depart~9431 Employer FEIN: _ _ _ _ _ __ E[Tiployee/Obligor's Name:L~E,__L~O=~---------------- SSN:XXX-XX-X281 Case Identifier: _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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: D This person has never worked for this employer nor received periodic income. D 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 telephone number: _ _ _ _ _ _ __ ---------------- Last known address: Final payment date to SOU/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 telephone: _ _ _ _ _ _ _ , by fax: _ _ _ _ _ _ _ • by email 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 telephone: _ _ _ _ _ _ _ . by fax: _ _ _ _ _ _ _ , by email or website: _ _ _ _ _ _ _ _ _ _ _ _ __ 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. Income \Mthholding for Support (IWO) Page 4 of 4