Fill - Free fillable IN THE CIRCUIT COURT OF THE FIFTHEENTH JUDICIAL (The 15th Judicial Circuit of Florida) PDF form

IN THE CIRCUIT COURT OF THE FIFTHEENTH JUDICIAL CIRCUIT

IN AND FOR PALM BEACH COUNTY, FLORIDA

In Re:

Petitioner, Case No.: _____________________

and

Family Division: ___

Respondent.

_____________________________________/

INCOME WITHHOLDING FOR SUPPORT ORDER AND FLORIDA ADDENDUM

 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/forms/OMB-0970-0154_instructions.pdf). 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 FLORIDA Remittance Identifier (include w/payment) ____________________

City/County/Dist./Tribe PALM BEACH 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 FLORIDA (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

Select one

Income Withholding for Support Order and Florida Addendum

Case No.

Page 2 of 7

OMB 0970-0154 and Florida Addendum,

$ ____________ 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 FLORIDA (State/Tribe),

you must begin withholding no later than the first pay period that occurs 14

days after the date of service of this IWO.

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 65

% of disposable income for all orders. If the employee/obligor’s

principal place of employment is not FLORIDA

(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.

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 STATE OF FLORIDA DISBURSEMENT UNIT (SDU/Tribal Order Payee)

at P.O. BOX 8500, TALLAHASSEE, FL 32314-8500 (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: ____________________________________________________________________

Title of Judge/Issuing Official: _________________________________________________________________________

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:

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.

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Income Withholding for Support Order and Florida Addendum

Case No.

Page 3 of 7

OMB 0970-0154 and Florida Addendum,

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.

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.

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.

_________________________________________________________________________________________________

Employer’s Name: __________________________________ Employer FEIN: ________________________________

Employee/Obligor’s Name: ___________________________________________________________________________

CSE Agency Case Identifier: _________________ Order Identifier: __________________________________________

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 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 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 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: _________________________

Income Withholding for Support Order and Florida Addendum

Case No.

Page 4 of 7

OMB 0970-0154 and Florida Addendum,

New employer’s name: _______________________________________________________________________________

New employer’s address: _____________________________________________________________________________

_________________________________________________________________________________________________

CONTACT INFORMATION:

To Employer/Income Withholder: If you have any questions, contact the Clerk of Circuit Court by phone at (561) 355-

2937 , by fax at , by email or website at:clerkweb@mypalmbeachclerk.com.

Send termination/income status notice and other correspondence to: Clerk of Circuit Court, Family Division, 205 North

Dixie Highway, West Palm Beach, FL 33401.

To Employee/Obligor: If the employee/obligor has questions, contact Clerk of Circuit Court by phone at (561) 355-2937

, by fax at , by email or website at clerkweb@mypalmbeachclerk.com.

IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.

Income Withholding for Support Order and Florida Addendum

Case No.

Page 5 of 7

OMB 0970-0154 and Florida Addendum,

FLORIDA ADDENDUM

THE PAYOR, {name} , IS HEREBY NOTIFIED that, under

sections 61.13 and 61.1301, Florida Statutes, you have the responsibilities and rights set forth below with

regard to the Income Withholding Order/Notice for Support:

1. The Income Withholding Order/Notice for Support is enforceable against employers specifically listed

upon the form as well as all subsequent employers/payors of Obligor, {name}

, {address}

2. You are required to deduct from the obligor’s income the amount specified in the income withholding

order, and in the case of a delinquency the amount specified in the notice of delinquency, and to pay

that amount to the State of Florida Disbursement Unit. The amount actually deducted plus all

administrative charges shall not be excess of the amount allowed under s. 303(b) of the Consumer

Credit Protection Act, 15 U.S.C. §1673(b), as amended.

3. You must implement income deduction no later than the first payment date which occurs more than

14 days after the date the income deduction order was served on you, and you shall conform the

amount specified in the income withholding order to the obligor’s pay cycle. The court should request

at the time of the order that the payment cycle will reflect that of the obligor.

4. You must forward, within 2 days after each date the obligor is entitled to payment from you, to the

State of Florida Disbursement Unit, the amount deducted from the obligor’s income, a statement as to

whether the amount totally or partially satisfies the periodic amount specified in the income

withholding order, and the specific date each deduction is made. If the IV-D agency is enforcing the

order, you shall make these notifications to the agency.

5. If you fail to deduct the proper amount from the obligor’s income, you are liable for the amount you

should have deducted, plus costs, interest, and reasonable attorneys’ fees.

6. You may collect up to $5 against the obligor’s income to reimburse you for administrative costs for the

first income deduction and up to $2 for each deduction thereafter.

7. The Income Withholding Order/Notice for Support is binding on you until further notice by court order

or until you no longer provide income to the obligor.

8. When you no longer provide income to the obligor, you shall notify the obligee,

{name}_________________________

__________________ {address}_______________________________________, and provide the

obligor’s last known address and the name and address of the obligor’s new payor, if known utilizing

the form contained within the Income Withholding Order/Notice for Support. If you violate this

provision, you are subject to a civil penalty not to exceed $250 for the first violation or $500 for any

subsequent violation. If the IV-D agency is enforcing the order, you shall make these notifications to

the agency instead of the obligee. Penalties shall be paid to the obligee or the IV-D agency,

whichever is enforcing the income deduction order.

9. You shall not discharge, refuse to employ, or take disciplinary action against an obligor because of

the requirement for income deduction. A violation of this provision subjects you to a civil penalty not to

exceed $250 for the first violation or $500 for any subsequent violation. Penalties shall be paid to the

obligee or the IV-D agency, whichever is enforcing the income deduction, if any alimony or child

support obligation is owing. If no alimony or child support obligation is owing, the penalty shall be paid

to the obligor.

10. The obligor may bring a civil action in the courts of this state against a payor who refuses to employ,

discharges, or otherwise disciplines an obligor because of income deduction. The obligor is entitled to

reinstatement of all wages and benefits lost, plus reasonable attorneys’ fees and costs incurred.

Income Withholding for Support Order and Florida Addendum

Case No.

Page 6 of 7

OMB 0970-0154 and Florida Addendum,

11. In a Title IV-D case, if an obligation to pay current support is reduced or terminated due to the

emancipation of a child and the obligor owes an arrearage, retroactive support, delinquency, or costs,

income deduction continues at the rate in effect immediately prior to emancipation until all arrearages,

retroactive support, delinquencies, and costs are paid in full or until the amount of withholding is

modified.

12. All notices to the obligee shall be sent to the address provided in this notice to payor, or anyplace

thereafter the obligee requests in writing.

13. An employer who employed 10 or more employees in any quarter during the preceding state fiscal

year or who was subject to and paid tax to the Department of Revenue in an amount of $20,000 or

more shall remit support payments deducted pursuant to an income deduction order or income

deduction notice and provide associated case data to the State Disbursement Unit by electronic

means approved by the department. Payors who are required to remit support payments

electronically can find more information on how to do so by accessing the State Disbursement Unit’s

website at www.floridasdu.com and clicking on “Payments.” Payment options include Expert Pay,

Automated Clearing House (ACH) credit through your financial institution, www.myfloridasdu.com, or

Western Union. Payors may contact the SDU Customer Service Employer telephone line at 1-888-

883-0743.

14. The amount of arrears owed, if any, is $________._ You must withhold an additional twenty percent

(20%) or more of the ongoing periodic obligation towards same at the rate of $_________ per

_________ until full payment is made of any arrearage, attorney's fees and costs – provided that no

deduction shall be applied to attorney's fees and costs until the full amount of any arrearage is paid.

If a delinquency accrues after the order establishing, modifying, or enforcing support has been

entered and there is no existing order for repayment of the delinquency or a pre-existing arrearage, a

payor shall deduct $___________ per ____________ (which represents an additional twenty percent

(20%) of the current support obligation, or other amount agreed to by the parties) until the

delinquency and any attorneys’ fees and costs are paid in full. No deduction may be applied to

attorneys’ fees and costs until the delinquency is paid in full.

15. Pursuant to sections 61.13 and 61.1301, Florida Statutes, the amounts listed for payment on the

Income Withholding Order must be varied by the employer/payor for bonus income, or similar one-

time payment.

You shall deduct [Choose only one] (___) the full amount, (___) _____%, or (____) none of the

income which is payable to the obligor in the form of a bonus or other similar one-time payment,

up to the amount of arrearage reported in the Income Deduction Order or the remaining

balance thereof, and forward the payment to the State of Florida Disbursement Unit. For

purposes of this subparagraph, “bonus” means a payment in addition to an obligor's usual

compensation and which is in addition to any amounts contracted for or otherwise legally due

and shall not include any commission payments due an obligor.

16. Child Support Reduction/Termination Schedule. Child support amount listed on this IWO shall be

automatically reduced or terminated as set forth in the following schedule:

Please list children

by initials from

eldest to youngest

Insert in this column

the day, month, and

year the child support

obligation terminates

for each designated

child (see instructions)

Insert in this column

the amount of child

support for all minor

children remaining

(including

designated child)

Child 1 (Eldest)

Initials & year of birth:

From the effective date of

this Income Deduction

Order until the following

date:

child support for Child 1 and

all other younger child(ren)

should be paid in the

following monthly amount:

Income Withholding for Support Order and Florida Addendum

Case No.

Page 7 of 7

OMB 0970-0154 and Florida Addendum,

Child 2

Initials & year of birth:

After the date set forth in the

row above until the following

date:

child support for Child 2 and

all other younger child(ren)

should be paid in the

following monthly amount:

Child 3

Initials & year of birth:

After the date set forth in the

row above until the following

date:

child support for Child 3 and

all other younger child(ren)

should be paid in the

following monthly amount:

Child 4

Initials & year of birth:

After the date set forth in the

row above until the following

date:

child support for Child 4 and

all other younger child(ren)

should be paid in the

following monthly amount:

(Continue on additional pages for additional children)

NOTE: This change only relates to the amount of the ongoing child support obligation portion of the

payments listed in the first page of this Income Withholding Order. If there is a child support

arrearage in a Title IV-D case, the amount will not be reduced due to the child no longer being

eligible for ongoing support pursuant to par. 11 above.

17. Additional information regarding the implementation of income deduction may be found at

www.florida.sdu.com.

DONE AND ORDERED in Chambers at ____________, PALM BEACH County, Florida, this _____

day of _____________ 20___.

________________________________

CIRCUIT JUDGE

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IN THE CIRCUIT COURT OF THE FIFTHEENTH JUDICIAL (The 15th Judicial Circuit of Florida)

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