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PACKAGE FEE: $2.10
INCOME DEDUCTION ORDER
Please contact the Clerk’s Office at (727) 464-7000 or visit us online at
www.mypinellasclerk.org for additional information.
10/2016
Ken BurKe, C.P.A.
ClerK of the CirCuit Court And ComPtroller
PinellAs County, floridA
www.mypinellasclerk.org
SELF HELP CENTER
The Self Help Centers are the result of a collaborative effort between the Clerk’s Office, the Sixth Judicial Circuit,
the Community Law Program and the Clearwater Bar Association.
The purpose of the Clerk's Legal Self Help Centers is to assist citizens representing
themselves in court (sometimes referred to as pro se persons) who do NOT have a private attorney.
Citizens who represent themselves in court and do not already have a private attorney representing them, can
now get affordable legal assistance.
OUR SERVICES INCLUDE:
• Schedule an appointment to consult with an attorney for a minimum of $15.00*
(Attorneys may assist with Family Law, Small Claims and Landlord/Tenant matters ONLY.)
• Purchase forms and packets for the civil court actions listes above
• Have documents notarized
• Make copies
Open Monday through Friday from 8:30 a.m. until 4:30 p.m.:
•
The Clearwater Self Help Center
The Clearwater Law Library, Old Clearwater
Courthouse
315 Court Street,
Clearwater, FL 33756
Phone: (727) 464-5150
Fax: (727) 453-3423
o Appointments may be scheduled for
Thursday and/or Friday.
o A Spanish interpreter provided by the
Hispanic Outreach Center is available by
appointment at the Clearwater location
on Fridays from 10:00 a.m. until 12:00 p.m.
•
The St. Petersburg Self Help
Center
The St. Petersburg Judicial Building
545 First Avenue North
St Petersburg, FL 33701
Phone: (727) 582-7941
Fax: (727) 582-7945
o Appointments may be scheduled for
Monday, Wednesday, and/or Friday.
• The North County Branch Self Help Center
29582 U.S. 19 North
Clearwater, FL 33761
Phone: (727) 464-5150
Fax: (727) 453-3423
o Attorney appointments may be scheduled
for Tuesday only at this office.
Self Help Center Now Offering Online Scheduling of attorney consultation appointments for pro se litigants
that do not already have an attorney. To schedule an appointment online using a credit card, please visit
www.mypinellasclerk.org
and click on the SELF HELP CENTER link in the top menu.
*Attorney appointments may only be scheduled for a minimum of 15 minutes to a maximum of one hour. All appointments must be
scheduled in 15-minute increments, i.e., 15, 30, 45 or 60 minutes at a rate of $1 (one dollar) per minute, therefore payments will be $15, $30,
$45 or $60 accordingly.
Attorney consultation fees must be paid when the appointment time is scheduled. Payments must be by credit card,cash check or money
order. Refunds will not be issued for missed appointments.
Ken Burke, CPA
Clerk of the Circuit Court
& Comptroller
Pinellas County, Florida
MAILINGCHARGESGUIDELINES
Thechartbelowcanbeusedasareferencewhendeterminingthetypeofenvelopeandthe
amountofpostageitwillcosttomailyoursummonsback.
Ifthepropersizeenvelopeandsufficientpostageisnotprovided,yoursummonswillnotbe
returnedormailed.
ENVELOPESIZE
#10OR6X9
WEIGHT
NUMBER OF
PAGES
COSTS
1oz 1‐6 .50
2oz 7‐11 .71
3oz 12‐17 .92
3.5 oz 18‐25 1.13
ENVELOPESIZE
FLATOR9X12
WEIGHT
NUMBER OF
PAGES
COSTS
1oz 1‐6 1.00
2oz 7‐12 1.21
3oz 13‐18 1.42
4oz 19‐23 1.63
5oz 24‐29 1.84
6oz 30‐37 2.05
7oz 38‐42 2.26
8oz 43‐48 2.47
9oz 49‐54 2.68
10oz 55‐59 2.89
11oz 60‐67 3.10
12oz 68‐73 3.31
13oz 74‐79 3.52
Ratesaresubjecttochange. YoumayvisittheUnitedStatesPostal
Servicesatwww.usps.comforuptodatepricing.
Paperweightwillvarycausingthepriceofthenumberofpagesper
ouncetochange.
The Sixth Circuit has adopted a locally approved form that should be used for income
withholding orders issued effective May 31, 2012.
The need for this form arose because the United States Department of Health and
Human Services issued Action Transmittal AT-11-05 in accordance with their authority
under the Social Security Act. Effective May 31, 2012, employers are required to reject
income withholding orders received after that date if they are not in compliance with
OMB Form 0970-0154. As pointed out by The Florida Bar Family Law Rules
Committee in SC12-618, the OMB form does not include provisions required under
Florida law. In order to have a form in place by the effective date of this new
requirement and have it available for the local Bar members, the Sixth Circuit has
adopted the OMB form plus the additional provisions required by state law into one
locally approved form.
This local form replaces the Family Law Income Deduction Order 12.996(a) until that
form is revised.
1
OMB 0970-0154 and Florida Addendum, Sixth Circuit Approved Family Law Form, Income Withholding for Support Order and Florida Addendum, 05/12
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PASCO / PINELLAS COUNTY, FLORIDA
, REF. NO.: ______________________
Petitioner, CASE NO.: _____________________
and
,
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 PASCO / PINELLAS 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
$ ____________ 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 __________________ .
2
OMB 0970-0154 and Florida Addendum, Sixth Circuit Approved Family Law Form, Income Withholding for Support Order and Florida Addendum, 05/12
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.
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.
SEE BELOW
3
OMB 0970-0154 and Florida Addendum, Sixth Circuit Approved Family Law Form, Income Withholding for Support Order and Florida Addendum, 05/12
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: _________________________
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/income status notice and other correspondence to: __________________________________________
___________________________________________________________________________________ (Issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact ______________________________ (Issuer name)
by phone at , by fax at , by email or website at ______________________________ .
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
4
OMB 0970-0154 and Florida Addendum, Sixth Circuit Approved Family Law Form, Income Withholding for Support Order and Florida Addendum, 05/12
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.
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
5
OMB 0970-0154 and Florida Addendum, Sixth Circuit Approved Family Law Form, Income Withholding for Support Order and Florida Addendum, 05/12
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:
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 ____________, PASCO / PINELLAS County, Florida, this _____ day of
_____________ 20___.
________________________________
CIRCUIT JUDGE
________________________________
PRINT NAME OF JUDGE
Instructions for Florida Family Law Rules of Procedure Form 12.996(b), Notice to Payor (09/12)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.996(b), NOTICE TO PAYOR (09/12)
When should this form be used?
This form should be used when an Income Deduction Order has been entered by the Court which is to
take effect immediately.
This form should be typed or printed in black ink. After completing this form, the original of this form
should be
filed with the clerk of the circuit court in the county in which the action is pending. You
should keep a copy for your own records.
What should I do next?
A copy of this form, and a copy of the Income Deduction Order, must be sent to the
obligor’s payor by
certified mail, return receipt requested. The return receipt should be sent to the person that prepared
this form so that it can filed with the clerk along with Florida Family Law Rules of Procedure Form
12.996(c), Notice of Filing Return Receipt.
A copy of this form must also be served on the other party or his or her attorney. Service must be in
accordance with Florida Rule of Judicial Administration 2.516.
Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. The words that are in “
bold underline” in these instructions are defined
there. For further information, see section 61.1301, Florida Statutes.
Special Instructions...
The Obligor’s social security number must be written on the copies of the Notice to Payor that are
mailed to the Obligor’s Payor and served on the other party or his or her attorney. The social security
number should not be written on the copy of the Notice to Payor filed with the court.
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.
Florida Family Law Rules of Procedure Form 12.996(b), Notice to Payor (09/12)
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
NOTICE TO PAYOR
TO:
Name of Obligor’s Payor:
Payor’s Address:
RE: Obligor Obligee
Name:
Address:
Obligor’s social security number:_________________________________.
NOTE: The Obligor’s social security number should be placed on the copy of the Notice to Payor that
is mailed to the Obligor’s Payor. This line should be left blank on the original Notice to Payor filed
with the court.
YOU, THE PAYOR, ARE HEREBY NOTIFIED that, under section 61.1301, Florida Statutes, you have the
responsibilities and rights set forth below with regard to the accompanying Income Deduction Order
and/or any attachment(s):
1. You are required to deduct from the obligor’s income the amount specified in the income deduction
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.
2. 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 deduction order or, in Title IV-D cases, income deduction notice 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.
3. 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
Florida Family Law Rules of Procedure Form 12.996(b), Notice to Payor (09/12)
to whether the amount totally or partially satisfies the periodic amount specified in the income
deduction order, or in Title IV-D cases, income deduction notice, 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.
4. 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;
5. 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.
6. The notice to payor, or, in Title IV-D cases, income deduction notice, and in the case of a
delinquency, the notice of delinquency, are binding on you until further notice by the obligee, IV-D
agency, or the court or until you no longer provide income to the obligor.
7. When you no longer provide income to the obligor, you shall notify the obligee and provide the
obligor’s last known address and the name and address of the obligor’s new payor, if known. 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.
8. 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.
9. 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.
10. The requirement for income deduction has priority over all other legal processes under state law
pertaining to the same income and that payment, as required by the notice to payor or the income
deduction notice, is a complete defense by the payor against any claims of the obligor or his or her
creditors as to the sum paid.
11. When you receive notices to payor or income deduction notices requiring that the income of two or
more obligors be deducted and sent to the same depository, the payor may combine the amounts
that are to be paid to the depository in a single payment as long as the payments attributable to
each obligor are clearly identified.
12. If you receive more than one notice to payor or income deduction notice against the same obligor,
the payor shall contact the court or, in Title IV-D cases, the Title IV-D agency for further instructions.
13. 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
Florida Family Law Rules of Procedure Form 12.996(b), Notice to Payor (09/12)
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.
14. All notices to the obligee shall be sent to the address provided in this notice to payor, or any place
thereafter the obligee requests in writing.
15. 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.myfloridacounty.com, or Western Union. Payors may contact the SDU Customer Service
Employer telephone line at 1-888-833-0743.
16. Additional information regarding the implementation of this Notice to Payor may be found at
www.florida.sdu.com.
I certify that a copy of this document was [check all used]: ( ) emailed ( ) mailed
( ) faxed ( ) hand delivered to the person(s) listed below on {date} _________________.
Other party or his/her attorney:
Name:
Address:
City, State, Zip: ________
Fax Number:
Email Address(es):______________________
Signature of Party or his/her attorney
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
E-Mail Address(es):___________________________
Florida Bar Number:___________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ___________________________________,
{name of business} _______________________________________________________________,
{street} ____________________________________________________________,
{city} ______________________________, {state} , {telephone number} _.
Instructions for Florida Family Law Rules of Procedure Form 12.996(c), Notice of Filing Return Receipt
(09/12)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.996(c) NOTICE OF FILING RETURN RECEIPT (09/12)
When should this form be used?
This form should be used when an Income Deduction Order, Florida Family Law Rules of
Procedure Form 12.996(a), is entered by the court and a Notice to Payor, Florida Family Law
Rules of Procedure Form 12.996(b), has been sent by certified mail to the
obligor’s payor. When
the post office returns the return receipt to you showing that the obligor’s payor has received
the Notice to Payor, you should type or print this form in black ink. After completing this form,
you should sign it and attach the return receipt you received from the post office. The original of
this form (and the attached return receipt) should be filed with the
clerk of the circuit court in
the county in which the action is pending. You should keep a copy for your own records.
What should I do next?
A copy of this form must also be served on the other party or his or her attorney. Service must
be in accordance with Florida Rule of Judicial Administration 2.516.
Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. The words that are in “bold underline” in these
instructions are defined there. For further information, see section 61.1301, Florida Statutes.
Special notes...
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill
out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping
you fill out these forms also must put his or her name, address, and telephone number on the
bottom of the last page of every form he or she helps you complete.
Florida Family Law Rules of Procedure Form 12.996(c), Notice of Filing Return Receipt (09/12)
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No: ________________________
Division: ________________________
_________________________________,
Petitioner,
and
_________________________________,
Respondent.
NOTICE OF FILING RETURN RECEIPT
{Name} ________________________________________________________________, the
[check only one] ( )Petitioner ( )Respondent, files the attached Return Receipt in reference
to the Notice to Payor sent by certified mail to {Payor’s name} __________________________,
the [check only one] ( ) Petitioner’s ( ) Respondent’s employer.
I certify that a copy of this document was [check all used]: ( ) emailed ( ) mailed ( ) faxed
( ) hand delivered to the persons(s) listed below on {date} ____________________________.
Other party or his/her attorney:
Name: _______________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: ___________________________________
Email Address(es):_______________________________
________________________________________________
Signature of Party or his/her Attorney
Printed Name: ___________________________
Address: ________________________________
City, State, Zip: ___________________________
Telephone Number: _______________________
Fax Number: _____________________________
Email Address(es):______________________
Florida Bar Number:________________________
Florida Family Law Rules of Procedure Form 12.996(c), Notice of Filing Return Receipt (09/12)
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS
BELOW: [fill in all blanks] This form was prepared for the: {choose only one}
( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} _________________________________________________________,
{name of business} ___________________________________________________________,
{street} _____________________________________________________________________,
{city} ______________________, {state} ______, {telephone number} ___________________.
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Ken BurKe, C.P.A. www.mypinellasclerk.org (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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