CURRENT AND/OR SUBSEQUENT EMPLOYER/INCOME PAYOR

INITIATING CHILD SUPPORT AGENCY

______________________________________________________
Name of Employer

__________________________________________
Name of initiating child support agency

___________________________________________
Address

___________________________________________
Address

INCOME PAYEE EMPLOYEE DATA
____________________________________________

PHONE # OF AGENCY
______________________________________

Name of Income Payee (Employee)
____________________________________________

Custodial Parent’s Name
___________________________________________

____________________________________________
Social Security Number

COURT INFORMATION
WASHINGTON SUPERIOR COURT
88D01-_______________________

AMOUNTS ARE PAYABLE TO :
CLERK OF WASHINGTON SUPERIOR COURT
99 PUBLIC SQUARE, SUITE 102
SALEM, INDIANA 47167

REMITTANCE MUST INCLUDE:
(1) Income payee's name
(2) Court cause number
(3) Custodial parent's name (4) Applicable pay period

Date notice was mailed______________________

YOU ARE HEREBY NOTIFIED:

(a) That the above named individual has a legal obligation to pay child support in the amount of $_______ , per____________, said order being issued by the above named court;

(b) That the above named individual is delinquent in the payment of support in the amount of $____________. This arrearage is: ____more than twelve (12) weeks old, _____less than twelve (12) weeks old.

(c) That the Court or other authorized agency has determined that, in addition to the base order, [see paragraph (a) above], this individual should pay the amount of $_______ per ____________ toward the liquidation of this arrearage until it is paid in full.

(d) Pursuant to Indiana Code 31-2-10, a Court has ordered that this obligation be discharged by means of immediate income withholding. The maximum applicable percentage of disposable income to be withheld from income paid to the above named payor based upon the information available to the Court or authorized agency is:

(check one) _____50% _______55% ________60% _______65% ________ UNKNOWN

(e) That the following order has priority over any secured or unsecured claim on income except claims for federal, state, and local taxes, and is binding until further notice from the Court or Child Support Agency listed above.

YOU ARE HEREBY ORDERED (PURSUANT TO I.C. 31-2-10):

(1) To withhold from weekly disposable earnings the collective sum of $_________per ________________
(or the equivalent based on your pay period) not to exceed the maximum amount permitted under the Consumer Credit Protection Act (15 USC 1673 (b), (see paragraph (d) above).

(2) To withhold from non-disposable earnings the entire amount of any lump sum distribution which is not subject to the requirements of I.C. 31-2-10-16.5 or 15 USC 1673 (b), but not to exceed the amount of the arrearage [see paragraph (b) above].

YOU ARE FURTHER NOTIFIED:

1. That the following are the maximum appropriate percentages of the individual's disposable income that may be deducted based upon the Consumer Credit Protection Act [15 USC 1673 (b)] restrictions:

A. 50% of the individual's disposable earnings for the week (pay period) because the individual is supporting another spouse and/or child(ren), other than a spouse or child(ren) with respect to whose support the order is issued

B. 55% of the individual's disposable earnings for the week (pay period) because the individual is more than twelve (12) weeks behind on the payment of the support obligation AND the individual is supporting another spouse and/or child(ren), other than a spouse or child(ren) with respect to whose support the order is issued

C. 60% of the individual's disposable earnings for the week (pay period) because the individual is NOT supporting another spouse and/or chid(ren), other than a spouse or child(ren) with respect to whose support the order is issued.

D. 65% of the individual's disposable earnings for the week (pay period) because the individual is NOT supporting another spouse and/or child(ren), other than a spouse or child(ren) with respect to whose support the order is issued AND the individual is more than twelve (12) weeks behind on the payment of the support obligation.

2. That you must forward the withheld income to the office listed on this order at the same time the income payee is paid. Your remittance must indicate the name of the income payee, the name of custodial parent and the court cause number. This information appears on the reverse side of this order. You are liable for any amount of income you fail to forward.

3. That you may retain' a two dollar ($2.00) fee from the income payee's income each time income withheld is forwarded. The sum total of the amount to be withheld plus this fee shall not exceed the maximum amount permitted under the Consumer Credit Protection Act.

4. That the income payee may recover in an action at law a sum not less than one hundred dollars ($100.00) from you as income payor if you discharge the income payee, refuse to employ the income payee, or discipline the income payee because you are required to forward income.

5. That amounts withheld under this statute have priority over any secured or unsecured claim on income except claims for federal, state and local taxes.

6. That if you are required to withhold income from more than one (1) income payee that is payable to the same office or Clerk, you may combine the withheld amounts in a single payment and separately identify the portion of the single payment that is attributable to each income payee.

7. That if there is more than one (1) income withholding in effect against a single income payee you must comply on a "pro rata" basis, honoring all orders for withholding to the extent that the total amount withheld from an income payee's income does not exceed the limits imposed by the Consumer Credit Protection Act.

8. That income withholding must be implemented no later than the first pay date after fourteen (14) days following the date you received this order.

9. You must notify the Child Support Agency listed on the reverse of this order that the income payee has terminated employment or has ceased receiving benefits within ten (10) days of termination, and provide the Agency with the individual's last known address and the name and address of the new employer or income payor if known.

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