**INCOME WITHHOLDING FOR SUPPORT**

**ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED
IWO**

**ONE-TIME ORDER/NOTICE - LUMP SUM PAYMENT**

**TERMINATION of IWO Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Child Support Enforcement (CSE) Agency Court Attorney Private
Individual/Entity (Check One)

**NOTE: ** If you receive this document from someone other than a State
or Tribal Child Support Enforcement agency or a court, a copy of the
underlying order that contains a provision authorizing income
withholding must be attached.  Or if under State law an attorney in that
State, or if under Tribal law a Tribal legal representative, may issue
an income withholding order, the attorney or Tribal legal representative
must include a copy of the State or Tribal law authorizing the attorney
or Tribal legal representative to issue an income withholding order.

State/Tribe/Territory
\_\_\_\_\_\_\_\_**\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Case
Identifier
\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City/County/Dist./Tribe
\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Order
Identifier
\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Private
Individual/Entity\_\_\_\_\_\_**\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
RE:
\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employer/Income Withholder's Name Employee/Obligor's Name (Last, First,
MI)

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employer/Income Withholder's Address Employee/Obligor's Social Security
Number (if known)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Custodial Party/Obligee's Name (Last, First, MI)

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employer/Income Withholder's Federal EIN

Child's Name (Last, First, MI) Child's Birth Date

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_

***ORDER INFORMATION**:* This document is based on the support or
withholding order from **\_\_\_\_\_\_\_\_.**

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 of \$\_\_\_\_\_\_\_**\_\_** per
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
to be forwarded to the payee below.

***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    \$ \_\_\_**\_\_\_**\_\_\_\_\_ per
  weekly pay period                   semimonthly pay period (twice a
                                      month)

  \$ **\_\_\_**\_\_\_\_\_ per         \$ \_\_\_**\_\_\_\_**\_\_\_\_ per
  biweekly pay period (every two      monthly pay period
  weeks)                              
  ----------------------------------- -----------------------------------

\$\_\_\_**\_\_**\_\_\_**\_\_ ONE-TIME 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
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_, 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
\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
see the ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME
WITHHOLDERS for limitations on withholding, applicable time requirements
and any allowable employer's fees.

For EFT/EDI instructions, contact the EFT/EDI office at the website
listed below. **If paying by check, make check payable to:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
**Include this *Remittance Identifier* with payment**:
\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_\_\_\_. **Send check
to**:
\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**FIPS code (If necessary)**: \_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_

Signature (if required by State or Tribal law):
\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title of Issuing Official:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If checked, you are required to provide a copy of this form to the
employee/obligor. 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 must be provided to the employee/obligor even if the box is not
checked.

**ADDITIONAL INFORMATION FOR EMPLOYERS AND OTHER INCOME WITHHOLDERS**

State-specific information may be viewed on the OCSE Employer Services
website located at:
http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contacts.htm

**Priority:** Withholding for support has priority over any other legal
process under State law (or Tribal law if applicable) against the same
income. If a Federal tax levy is in effect, please notify the contact
person listed below.

**Combining Payments:** You may combine withheld amounts from more than
one employee/obligor's income in a single payment to each agency/party
requesting withholding. You must, however, separately identify the
portion of the single payment that is attributable to each
employee/obligor.

**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 with respect to the time periods within which you
must implement the withholding and forward the support payments.

**Employee/Obligor with Multiple Support Withholdings:** If there is
more than one Order/Notice against this employee/obligor and you are
unable to fully honor all support Orders/Notices due to federal, State,
or Tribal withholding limits, you must follow the State or Tribal
law/procedure of the employee/obligor's principal place of employment.
You must honor all Orders/Notices to the greatest extent possible,
giving priority to current support before payment of any past-due
support.

**Lump Sum Payments:** You may be required to report and withhold from
lump sum payments such as bonuses, commissions, or severance pay.
Contact the agency or person listed below to determine if you are
required to withhold or if you have any questions about lump sum
payments.

**Liability:** If you have any doubts about the validity of the
Order/Notice, contact the agency or person listed below. If you fail to
withhold income as the Order/Notice directs, you are liable for both the
accumulated amount you should have withheld from the employee/obligor's
income and any other 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 a child support withholding.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**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. 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, that 50% limit is increased to 55% and that 60% limit is
increased to 65% if the arrears are greater than 12 weeks. If permitted
by the State, you may deduct a fee for administrative costs. The support
amount and the fee may not exceed the limit indicated in this section.

**Arrears greater than 12 weeks?** If the *Order Information* does not
indicate whether the arrears are greater than 12 weeks, then the
employer should calculate the CCPA limit using the lower percentage.

For Tribal orders, you may not withhold more than the amounts allowed
under the law of the issuing Tribe. For Tribal employers who receive a
State order, you may not withhold more than the lesser of the limit set
by the law of the jurisdiction in which the employer 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, you may need to take into
consideration the amounts paid for health care premiums in determining
disposable income and applying appropriate withholding limits.

**Additional Information:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NOTIFICATION OF TERMINATION OF EMPLOYMENT:** You must promptly notify
the Child Support Enforcement agency and/or the person listed below by
returning this form to the correspondence address if:

-   This person has never worked for this employer.

-   This person no longer works for this employer.

Please provide the following information for the terminated employee:

Termination date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Last known
phone number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Last known home address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date final payment made to the State Disbursement Unit or Tribal CSE
agency: \_\_\_\_\_\_\_\_\_\_\_

Final payment amount: \_\_\_\_\_\_\_\_\_\_ New employer's name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

New employer's address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**CONTACT INFORMATION**

**[To employer:]{.underline}** If the employer/income withholder has any
questions, contact
\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ by phone at
\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_, by fax at
\_\_\_\_\_\_\_\_**\_\_\_**\_\_\_\_\_\_\_\_, by email or website at:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_[.]{.underline}

Send termination notice and other correspondence to:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[To employee/obligor:]{.underline}** If the employee/obligor has
questions, contact
\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_ by phone at
\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_, by
fax\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_, by
email or website at

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_