Employer’s Name: _________________________ Employer FEIN: ________________________________________________
Employee/Obligor’s Name: ____________________________________ SSN: ______________________
CSE Agency Case Identifier: ____________________ Order Identifier: ______________________________________________
Page 3 of 7 – INCOME WITHHOLDING FOR SUPPORT
CSF 11 0210 (OMB Exp. 08/31/20) CSCM: `
Tracking Document ID OMB 0970-0154
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.
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/obligor’s principal place of employment, if the place of employment is in a state; or tribal law of the
employee/obligor’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 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.
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 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: Oregon withholders for additional information, see the attached “Information for Withholders
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 telephone number: ________________