Order Or Notice To Withhold Income For Child And Spousal Support {DJFS 4047}

JFS 04047 (Rev. 12/2002) Mahoning County Revision July 2006 Page 1 of 4 ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD & SPOUSAL SUPPORT (Ohio Revised Code 3121.037) STATE: OHIO County: MAHONING Date of Issuance:________________ Order Number:_________________ FIPS Code:_____________________ _______________________________________ Employer/Withholder's Federal EIN Number Employer/Withholder's Name and Address: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Worker's Compensation Claim Number _______________________________________________ Financial Institution Account Number ____Checking _____Savings Child(ren)'s Name(s): _____________________________ _____________________________ _____________________________ D.O.B. ____________ ____________ ____________ _______________________________________________ Custodial Parent's Name(Last, First, M.I.) Child(ren)'s Name(s): _________________________ _________________________ _________________________ D.O.B. _____________ _____________ _____________ _______________________________________________ Employee/Obligor's Case Number _______________________________________________ Employee/Obligor's Date of Birth _____Original Order/Notice _____Amended Order/Notice _____Terminate Order/Notice RE:___________________________________________ Employee/Obligor's Name (Last, First, M.I.) _______________________________________________ Employee/Obligor's Social Security Number ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from Mahoning County Domestic Relations or Juvenile Court. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until the director or designee of the county child support enforcement agency notifies you in writing to terminate or reduce the withholding even if the Order/Notice is not issued by your State. If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment and to inform the child support enforcement agency of any lapses in coverage. $________________________per month in current support (child and spousal) $________________________per month in past-due child support $________________________per month in medical support $________________________per month ­ Subtotal (for Ohio Bureau of Employment Services Withholding) $________________________per month in processing fees For a Total of $_____________________ per month to be forwarded to the payee below. THIS OBLIGOR'S ____________________________ PAY PERIOD DEDUCTION IS $__________________________. (Weekly, Biweekly, Semimonthly) Arrears 12 weeks or greater? __yes __no JFS 04047 (Rev. 12/2002) American LegalNet, Inc. www.FormsWorkflow.com JFS 04047 (Rev. 12/2002) Mahoning County Revision July 2006 Page 2 of 4 You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: 1.If pay cycle is weekly, multiply the monthly amount by 12 and divide by 52. 2.If pay cycle is every other week, multiply monthly amount by 12 and divide by 26. 3.If pay cycle is twice monthly, multiply monthly amount by 12 and divide by 24. REMITTANCE INFORMATION: An employer must begin withholding no later than the first pay period occurring fourteen working days after the date of this Order/Notice. Send payment IMMEDIATELY or within seven (7) working days of the pay date/date of withholding. Ohio Law. Financial Institutions are required to send the amount deducted no later than fourteen (14) working days following the date this notice was mailed and are required to continue the deduction thereafter. IMMEDIATELY, but not later than seven (7) working days after the payment or deduction is made. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of the employee for the allowable amount. Ohio Law. A withholder may deduct a fee of $2.00 or 1% of the amount withheld, whichever is greater (including an employer paying workers' compensation). A financial institution may deduct a fee of $5.00 or a fee not to exceed the lowest rate, if any, charged for a similar debt transaction, whichever is less of the amount specified to be withheld. The total withheld amount, including your fee, cannot exceed 65% of the employee's/obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (see #9 for more information). When remitting payment, provide the Pay date/Date of Withholding, Obligor's Name, Social Security Number, Case number and the Order Number. When remitting for more than one obligor, include the amount of payment for each person. If you choose to remit by EFT/EFI, contact Ohio Child Support Payment Central to obtain bank file format (See Page 4 of this document) Make check payable to: Ohio Child Support Payment Central (CSPC) P. O. Box 182394 Columbus, OH 43218 Authorized by: MAHONING COUNTY DOMESTIC RELATIONS OR JUVENILE COURT If you or your employee/obligor have any questions, contact: CASE SUPPORT SPECIALIST by telephone at : (330) 740-2073 OR 1800-528-9511 or by FAX at: (330) 884-6962., or by mail at 709 North Garland, P.O. Box 119, Youngstown, OH 44501-0119. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS If checked you are required to provide a copy of this form to your employee. 1.Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income . Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2.Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. employee/obligor. 3.* You must, however, separately identify the portion of the single payment that is attributable to each Reporting the Pay date/Date of Withholding: You must report the pay date/date of withholding when sending the payment. The pay date/date of withholding is the date on which amount was withheld fr