Parties & Case Info

a. General Information

Date: Write the date you are filling out this form. Use month, day, and year.

b. Child Support

Child Support Agency (CSA) Check this box if a child support agency is sending this form. Court Check this box if a court is sending this form. Attorney Check this box if a lawyer is sending this form. Private Individual/Entity (Check One) Check this box if a private person or company is sending this form. State/Tribe/Territory Write the name of the state, tribe, or territory that issued this order. Remittance ID (include w/payment) Write the ID number that should be included with each payment. This helps match the money to the right case. City/County/Dist./Tribe Write the city, county, district, or tribe that issued this order. Order ID Write the number used to identify the support order. Private Individual Entity Write the name of the private person or company if one is sending this form. Case ID Write the case number for this support case. RE: Write what or who this order is about, such as the person's name. Employer/Income Withholder's Name Write the name of the employer or company that pays the person and will take out the money. Employee/Obligor's Name (Last, First, Middle) Write the full name of the person who must pay support. List last name first. Employer/Income Withholder's Address Write the mailing address of the employer or company that will take out the money. Employee/Obligor's Social Security Number Write the Social Security number of the person who must pay support.

c. Children's Basic Information

Employee/Obligor's Date of Birth Write the birth date of the person who must pay support. Custodial Party/Obligee's Name (Last, First, Middle) Write the full name of the person who gets the support, usually the parent the child lives with. List last name first. Employer/Income Withholder's FEIN Write the employer's federal tax ID number (FEIN) if you know it. Employer/Income Withholder's Name: Enter the full name of the employer or company that pays the employee's wages and will take out the support money. Employer/Income Withholder's FEIN: Enter the employer's Federal Employer Identification Number (FEIN). This is the tax ID number used by the IRS to identify the business. Employee/Obligor's Name: Enter the full name of the worker who owes support and whose pay will be withheld. SSN: Enter the Social Security number of the employee who owes support. This helps match the order to the right person. Case ID: Enter the case ID number for this support case. You can find it on the court papers or order. Order ID: Enter the order ID number listed on the support order. This may be different from the case ID. Employer/Income Withholder's Name: Write the full name of the company or person who pays the employee and will take money out of their paycheck. Employer/Income Withholder's FEIN: Enter the employer's Federal Employer Identification Number, which is like a tax ID for the business. Employee/Obligor's Name: Write the full name of the person who owes the support and whose pay will be withheld. SSN: Enter the Social Security number of the person who owes the support. Case ID: Enter the case number used by the child support agency or court for this matter. Order ID: Enter the order number that identifies the specific support order, if you have one. Employer/Income Withholder's Name: Write the name of the company or person that pays the employee and handles the withholding. Employer/Income Withholder's FEIN: Enter the employer's Federal Employer Identification Number, a tax ID used by businesses. Employee/Obligor's Name: Write the full name of the worker who owes the support payments. SSN: Enter the worker's Social Security number so the case can be matched correctly. Case ID: Enter the case number that the child support agency assigned to this case. Order ID: Enter the order number listed on the support order documents. This order is effective Enter the date when this withholding order starts. After this date, all the payment rules listed on page 2 will apply.