AUTHORIZATION FOR WAGE WITHHOLDING

 

 

 

Name:  ____________________________________________________,  ________________________________________________,  ____________

            Last                                                                                                    First                                                                                          Middle

 

Your Social Security Number:                 - -   

 

Your Address:  ___________________________________________________________________________, Apt. No. ________________

 

City: _____________________________________________________________________, State: ___________, Zip: _________________

 

Your Phone: ( _______)  _____________________________

 

Court Order Number : __________________________________________________________County: _________________________________________

 

Court Case Caption:   ____________________________________________  Vs. __________________________________________________________

 

Clerk of the District Court Address: ________________________________________________________________________________________________

 

City: _______________________________________________________________________________________, State: ___________, Zip: ___________

 

In accordance with my court order, I hereby authorize my employer to withhold payments from my regular wages in the amounts specified below:

 

Check One:

 

           Monthly Paycheck                                                                                           Semi-monthly Paycheck

 

                Amount $ _______________                                                                 Amount $ _______________

 

           Bi-weekly Paycheck                                                                                         Weekly Paycheck

               

Amount $ _______________                                                                 Amount $ _______________

 

* A separate authorization from must be completed for each type of payment specified below:

 

Check One:                                                                                           * Check One Payment Type:                                                                                                              

           NEW Authorization                                                                                           Child Support Payment

 

           CHANGE Authorization                                                                    Medical  Support Payment

 

           CANCEL Authorization                                                                     Alimony/Spousal Support Payment

 

                                                                                                                           Property Settlement Payment

 

                                                                                                                           Child/Day Care Payment

 

I understand my employer will automatically withdraw the amount specified from my paycheck, and my employer will automatically transfer this amount to the Nebraska Child Support Payment Center for the following types of payments: Child Support, Medical Support, Alimony/Spousal support (if included in the order for child support).  All other types of support payments which include: Alimony/Spousal (if not included in the order for child support), property settlement, and child/day care payments will be automatically transferred to the clerk of the district court, which will credit this amount to the judgement indicated above.

 

AUTHORIZATION AGREEMENT

 

I UNDERSTAND THAT I AM RESPONSIBLE FOR INFORMING MY EMPLOYER IN WRITING OF ANY CHANGES IN THIS AUTHORIZATION.  I ALSO UNDERSTAND THAT MY SUPPORT ORDER SPECIFIES THE DAY(S) ON WHICH MY PAYMENT(S) IS (ARE) DUE, AND I AM AWARE OF MY RESPONSIBILITIES.  I FURTHER UNDERSTAND THAT IF THE SPECIFIED DAY(S) FALL(S) ON A HOLIDAY, WEEKEND OR ANY DAY OTHER THAN A NORMAL WORKDAY, MY DEDUCTION WILL BE PROCESSED ON THE FOLLOWING BUSINESS DAY.

 

THIS AUTHORIZATION REMAINS IN FORCE UNTIL MY EMPLOYMER RECEIVES WRITTEN NOTICE OF CANCELLATION FROM ME.

 

 

 

 

_______________________________________________________________________________  ______________________________

Signature                                                                                                                                                                Date