Fillable EarningsAssignment Superior Court of California

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EarningsAssignment Superior Court of California

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Superior Court of California
County of San Bernardino
Income Withholding Order for Support Cover Sheet
Person Completing Form
Name (Last, First, MI):
Address:
City, State, Zip Code:
Telephone Number (home or cellular):
Party Ordered to Pay Support
Name (Last, First, MI):
Party Receiving Support:
Name (Last, First, MI):
What is your case number?
Have you previously received an Income Withholding Order for Support?
Yes No
What is the name/ address of the employer of the party ordered to pay support?
Employer Name:
Employer Address:
City, State, Zip Code:
What is the Social Security Number of the party ordered to pay support?
Social Security Number (last 4 digits only): XXX-XX-
List all minor children’s names and dates of birth in the order for support?
Name: Name:
DOB: DOB:
Name: Name:
DOB: DOB:
Please enter the following information:
Child Support per Month: $
Past Due Child Support per Month (only enter an amount if the court ordered payment): $
Is the past due amount more than 12 weeks old? Yes No
Spousal Support per Month: $
Past Due Spousal Support per Month (only enter an amount if the court ordered payment): $
Today’s Date:
Print These Forms
Clear These Forms
FL-195
Document Tracking Identifier 1
INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION of IWO Date:
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 http://www.acf.hhs.gov/programs/cse/newhire/employer/publication/publication.htm - forms).
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 Remittance Identifier (include w/payment)
City/County/Dist./Tribe Order Identifier
Private Individual/Entity CSE Agency Case Identifier
RE:
Employer/Income Withholder’s Name Employee/Obligor’s Name (Last, First, Middle)
Employer/Income Withholder’s Address Employee/Obligor’s Social Security Number
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)
ORDER INFORMATION: This document is based on the support or withholding order from (State/Tribe).
You are required by law to deduct these amounts from the employee/obligor’s income until further notice.
$ Per current child support
$ Per past-due child support - Arrears greater than 12 weeks? Yes 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 $ per .
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:
$
per weekly pay period
$
per semimonthly pay period (twice a month)
$
per biweekly pay period (every two weeks)
$
per monthly pay period
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
REMITTANCE INFORMATION: If the employee/obligor’s principal place of employment is (State/Tribe),
you must begin withholding no later than the first pay period that occurs days after the date of . Send
payment within
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
% of disposable income for all orders. If the employee/obligor’s principal
place of employment is not
(State/Tribe), obtain withholding limitations, time requirements, and any
allowable employer fees at
http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm for the
employee/obligor’s principal place of employment.
California
San Bernardino
XXX-XX-
California
Month
Month
Month
Month
Month
Month
Month
0.00
0.00
0.00
0.00
Month
0.00
California
10
SERVICE
7
50
California
FL-195
OMB Expiration Date – 05/31/2014. 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
For electronic payment requirements and centralized payment collection and disbursement facility information (State
Disbursement Unit [SDU]), see
http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm.
Include the Remittance Identifier with the payment and if necessary this FIPS code:
Remit payment to (SDU/Tribal Order Payee)
at (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.
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that must 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 employer/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact_map.htm
Priority: Withholding for support has priority over any other legal process under State law against the same income
(USC 42 §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.
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.
Signature of Judge/Issuing Official (if required by State or Tribal law):
Print Name of Judge/Issuing Official:
Title of Judge/Issuing Official:
Date of Signature:
STATE DISBURSEMENT UNIT (SDU)
PO Box 989067, West Sacramento, CA 95798-9067
JUDGE OF THE SUPERIOR COURT
✔
FL-195
Employer’s name:
Employer FEIN: __
Employee/Obligor’s Name:
CSE Agency Case Identifier:
Order Identifier __
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. 3
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer
Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor’s
principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making
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 the 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 withholder who receive a State IWO, you may not withhold more than the lesser of the limit set by the law
of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section
303(d) of the CCPA (15 U.S.C. 1673 (b)).
Depending upon applicable State law or Tribal law, you may need to also consider the 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.
Additional Information:
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, an employer 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 any questions, contact (Issuer name)
by phone at
, by fax at , by email or website at: .
Send termination notice and other correspondence to:
(Issuer address).
To Employer/Obligor: If the employee/obligor has questions, contact (Issuer name)
by phone at
, by fax at , by email or website at: .
FL-191
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
COURT PERSONNEL:
STAMP DATE RECEIVED HERE
DO NOT FILE
CHILD SUPPORT CASE REGISTRY FORM
CASE NUMBER:
Mother First form completed
Father
THIS FORM WILL NOT BE PLACED IN THE COURT FILE. IT WILL BE
MAINTAINED IN A CONFIDENTIAL FILE WITH THE STATE OF CALIFORNIA.
Notice: Pages 1 and 2 of this form must be completed and delivered to the court along with the court order for support.
Pages 3 and 4 are instructional only and do not need to be delivered to the court. If you did not file the court order, you must
complete this form and deliver it to the court within 10 days of the date on which you received a copy of the support order.
Any later change to the information on this form must be delivered to the court on another form within 10 days of the
change. It is important that you keep the court informed in writing of any changes of your address and telephone number.
ModificationInitial child support or family support orderb.
Total monthly base current child or family support amount ordered for children listed below, plus any monthly amount ordered
payable on past-due support:
(1) Current
base child
support:
(2) Additional
monthly
support:
Person required to pay child or family support (name):
Relationship to child (if applicable):
Person or agency to receive child or family support payments (name):
TYPE OR PRINT IN INK
Page 1 of 4
Family Code, § 4014
Form Adopted for Mandatory Use
Judicial Council of California
FL-191 [Rev. July 1, 2005]
CHILD SUPPORT CASE REGISTRY FORM
www.courtinfo.ca.gov
Change to previous information
Relationship to child (specify):
TELEPHONE NO.: FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
(5)
ordered but stayed until (date):
Wage withholding was
Support order information (this information is on the court order you are filing or have received).
or
dered
(3) Total
past-due
support:
$
$
$
Date order filed:
1.
3.
2.
a.
c.
Child Support:
Family Support:
Spousal Support:
$0 (zero) order
Reserved order
(4) Payment
on past-
due support:
$
Current
base family
support:
Additional
monthly
support:
Total
past-due
support:
$
$
$
$0 (zero) order
Reserved order
Payment
on past-
due support:
$
Current
spousal
support:
Total
past-due
support:
$
$
$0 (zero) order
Reserved order
Payment
on past-
due support:
$
Self-Represented
San Bernardino
SELECT
SELECT
You are required to complete the following information about yourself. You are not required to provide information about the other
person, but you are encouraged to provide as much as you can. This form is confidential and will not be filed in the court file. It will be
maintained in a confidential file with the State of California.
Father’s name:
Date of birth:
Social security number:
Street address:
City, state, zip code:
Mailing address:
Driver’s license number:
State:
Telephone number:
Self-employedEmployed Not employed
g.
Employer’s name:
Street address:
City, state, zip code:
Telephone number:
7.
A restraining order, protective order, or nondisclosure order due to domestic violence is in effect.
Father
Mother
Children
The order protects:
Father
Mother
From:
The restraining order expires on (date):
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF PERSON COMPLETING THIS FORM)
Page 2 of 4
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
a.
b.
c.
5.
a.
b.
c.
d.
e.
f.
Mother’s name:
Date of birth:
Social security number:
Street address:
City, state, zip code:
Mailing address:
City, state, zip code:
Driver’s license number:
State:
Telephone number:
Self-employedEmployed Not employed
g.
Employer’s name:
Street address:
City, state, zip code:
Telephone number:
a.
b.
c.
6.
d.
e.
f.
City, state, zip code:
PETITIONER/PLAINTIFF:
CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
The child support order is for the following children:
Date of birth
Social security number
a.
b.
Additional children are li
sted on a page attached to this document.
Child’s name
4.
c.
INFORMATION SHEET FOR CHILD SUPPORT CASE REGISTRY FORM
(Do NOT deliver this Information Sheet to the court clerk.)
Please follow these instructions to complete the Child Support Case Registry Form (form FL-191) if you do not have an attorney to
represent you. Your attorney, if you have one, should complete this form.
Both parents must complete a Child Support Case Registry Form. The information on this form will be included in a national database
that, among other things, is used to locate absent parents. When you file a court order, you must deliver a completed form to the court
clerk along with your court order. If you did not file a court order, you must deliver a completed form to the court clerk WITHIN 10 DAYS
of the date you received a copy of your court order. If any of the information you provide on this form changes, you must complete a
new form and deliver it to the court clerk within 10 days of the change. The address of the court clerk is the same as the one shown for
the superior court on your order. This form is confidential and will not be filed in the court file. It will be maintained in a confidential file
with the State of California.
INSTRUCTIONS FOR COMPLETING THE CHILD SUPPORT CASE REGISTRY FORM (TYPE OR PRINT IN INK):
If the top section of the form has already been filled out, skip down to number 1 below. If the top section of the form is blank, you
must provide this information.
Page 1, first box, top of form, left side
: Print your name, address, telephone number, fax number, and e-mail address, if any, in this box.
Attorneys must include their State Bar identification numbers.
Page 1, second box, top of form, left side
: Print the name of the county and the court’s address in this box. Use the same address for
the court that is on the court order you are filing or have received.
Page 1, third box, top of form, left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box.
Use the same names listed on the court order you are filing or have received.
Page 1, fourth box, top of form, left side
: Check the box indicating whether you are the mother or the father. If you are the attorney for
the mother, check the box for mother. If you are the attorney for the father, check the box for father. Also, if this is the first time you
have filled out this form, check the box by "First form completed.” If you have filled out form FL-191 before, and you are changing any
of the information, check the box by “Change to previous information.”
Page 1, first box, right side
: Leave this box blank for the court’s use in stamping the date of receipt.
Page 1, second box, right side
: Print the court case number in this box. This number is also shown on the court papers.
Instructions for numbered paragraphs:
Enter the date the court order was filed. This date is shown in the “COURT PERSONNEL: STAMP DATE RECEIVED HERE" box
on page 1 at the top of the order on the right side. If the order has not been filed, leave this item blank for the court clerk to fill in.
If the court order you filed or received is the first child or family support order for this case, check the box by “Initial child support
or family support order." If this is a change to your order, check the box by “Modification.”
Information regarding the amount and type of support ordered and wage withholding is on the court order you are filing or have
received.
If your order provides for any type of current support, check all boxes that describe that support. For example, if your order
provides for both child and spousal support, check both of those boxes. If there is an amount, put it in the blank provided. If
the order says the amount is reserved, check the “Reserved order” box. If the order says the amount is zero, check the “$0
(zero) order" box. Do not include child care, special needs, uninsured medical expenses, or travel for visitation here These
amounts will go in (2). Do NOT complete the Child Support Case Registry form if you receive spousal support only.
If your order provides for a set monthly amount to be paid as additional support for such needs as child care, special needs,
uninsured medical expenses or travel for visitation check the box in Item 2 and enter the monthly amount. For example, if
your order provides for base child support and in addition the paying parent is required to pay $300 per month, check the box
in item 2 underneath the "Child Support" column and enter $300. Do NOT check this box if your order provides only for a
payment of a percentage, such as 50% of the childcare.
Page 3 of 4
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
1. a.
b.
c.
(1)
(2)
Write the name of the person who is supposed to pay child or family support.
Write the name of the person or agency supposed to receive child or family support payments.
List the full name, date of birth, and social security number for each child included in the support order. If there are more than five
children included in the support order, check the box below item 4e and list the remaining children with dates of birth and social
security numbers on another sheet of paper. Attach the other sheet to this form.
The local child support agency is required, under section 466(a)(13) of the Social Security Act, to place in the records pertaining to
child support the social security number of any individual who is subject to a divorce decree, support order, or paternity determination
or acknowledgment. This information is mandatory and will be kept on file at the local child support agency.
Top of page 2, box on left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box. Use the
same names listed on page 1.
Top of page 2, box on right side
: Print your court case number in this box. Use the same case number as on page 1, second box,
right side.
You are required to complete information about yourself. If you know information about the other person, you may also fill in what you
know about him or her.
If you are the father in this case, list your full name in this space. See instructions for a–g under item 6 below.
If you are the mother in this case, list your full name in this space.
List the street address, city, state, and zip code where you want your mail sent, if different from the address where you live.
Indicate whether you are employed, not employed, self-employed, or by checking the appropriate box. If you are employed, write
the name, street address, city, state, zip code, and telephone number where you work.
If there is a restraining order, protective order, or nondisclosure order, check this box.
Check the box beside the parent who is restrained.
Write the date the restraining order expires. See the restraining order, protective order, or nondisclosure order for this date.
If you are in fear of domestic violence, you may want to ask the court for a restraining order, protective order, or nondisclosure order.
You must type or print your name, fill in the date, and sign the Child Support Case Registry Form under penalty of perjury. When you
sign under penalty of perjury, you are stating that the information you have provided is true and correct.
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
Page 4 of 4
If your order provides for a specific dollar amount to be paid towards any past due support, check the box in Item 4 that states
the type of past due support and enter the amount. For example, the court ordered $350 per month to be paid on the past due
child support, you would check the box in Item 4 in the "Child Support" column and enter $350.
If your order determined the amount of past due support, check the box in Item 3 that states the type of past due support and
enter the amount. For example, if the court determined that there was $5000 in past due child support and $1000 in past due
spousal support, you would check the box in item 3 in the "Child Support" column and enter $5000 and you would also check
the box in item 3 in the "Spousal Support" column and enter $1000.
(3)
(4)
2. a.
b.
3. a.
b.
4.
Write the relationship of that person to the child.
Write the relationship of that person to the child.
6.
5.
Check the box beside each person who is protected by the restraining order.
List your date of birth.
Write your social security number.
List the street address, city, state, and zip code where you live.
Write your driver's license number and the state where it was issued.
List the telephone number where you live.
7.
a.
b.
c.
d.
e.
f.
g.
a.
b.
c.
Check the "ordered" box if wage withholding was ordered with no conditions. Check the box "ordered but stayed until" if wage
withholding was ordered but is not to be deducted until a later date. If the court delayed the effective date of the wage
withholding, enter the specific date. Check only one box in this item.
(5)
Follow these simple steps in order to successfully file your
paperwork.
Review
After you have completed your forms, bring them back to one of our local Resource Centers
to have them reviewed. It is important to follow this step because our staff has been
trained to review these forms and help you make any necessary changes.
Copy
Make (2) copies of your corrected originals and then you will be ready to file your
paperwork.
File
After copying, take your original and the (2) sets of copies, and (1) self addressed
envelope with a postage stamp to the clerk’s office within the court house where your case
is currently located. Please keep in mind that it may take a few weeks for the court to
process your request.
Finishing up
When you receive the (2) copies of the court order then you will keep (1) copy for your
records and send the other copy to the employer of the person ordered to pay support.
WhatistheStateCaseRegistryForm?
TheChildSupportCaseRegistryForm(FL‐191)wascreatedtocomplywiththefederal
lawthatrequireseachstatetocreateastatewidecaseregistryandsingleprocessing
centerforchildsupportpayments.Theformmustbecompletedandreturnedtothe
courtclerkbybothparentswhenanorderforchildsupportismade.TheCaseRegistry
Formhelpstoensurethatchildsupportpaymentsarecollectedanddistributed
accuratelybythestate.Whenneededthecaseregistrycanalsoassistlocatingabsent
parents.Thecourtclerkdoesnotfiletheform;instead,theformissenttotheStateof
Californiaandkeptinaconfidentialfilethere.
WhenistheChildSupportRegistryFormCompleted?
TheparentaskingthecourttoissuetheIncomeWithholdingOrderdeliverstothecourt
clerkacompletedRegistryFormFL‐191alongwiththecompletedIncomeWithholding
Order.TheotherpartyshouldcompleteandfiletheircompletedRegistryFormFL‐191
within10daysofreceivingacopyoftheIncomeWithholdingOrder.Theinformation
gatheredintheRegistryiskeptinanationaldatabase.
CompletingtheChildSupportCaseRegistryForm(FL‐191)ismandatory.
FailuretoprepareandfilethisformmaypreventtheStateDisbursementUnitfrom
beingabletocollectandsendthechildsupportpaymentswithoutinterruption.
WhatistheStateDisbursementUnit(SDU)?
FederalLawrequiresallstatestoestablishacentrallocationforprocessingchild
supportpayments.CaliforniahascreatedtheStateDisbursementUnit
(SDU)tomeet
thisrequirement.TheSDUreceivesandprocessesallprivate(non‐TitleIV‐D)child
supportpaymentsmadebywageassignment.
HowDoestheStateDisbursementUnit(SDU)ProcessPayments?
Oncethewageassignmentorderisissuedbythecourt,itisforwardedtothe
employerofthepersonwhoowessupport.[Thepersonwhofiled
thewage
assignmentforwardstheissuedwageassignmentordertotheemployer.=]
TheemployersendsthechildsupportpaymentstotheSDU.
TheSDUprocessesthepaymentsfromtheemployerandthenforwardsthe
paymenttotheparentowedsupportattheaddresscontainedintheStateCase
Registry.
FormoreinformationabouttheCaliforniaStateDisbursementUnit,theCaliforniaDepartment
ofChildSupportServiceshasestablishedthefollowingwebsite:
www.casdu.com.Inaddition,aSDUCustomerServiceHelpDeskphonenumberisavailableat:
1‐866‐901‐3212.
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EarningsAssignment Superior Court of California

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Completed 3 July 2020

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