FL-195 - Income Withholding for Support

Summary

Income Withholding for Support

Text

Form ID: FL-195
Title: Income Withholding for Support
Effective Date: 2024-01-22
Mandatory Form: no
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-195
Primary Download URL: https://www.courts.ca.gov/documents/fl195.pdf
Form Detail Page:
Income Withholding for Support
(FL-195)
Tells an employer that the court made an order for you or the other person in the case to pay child support, medical support, spousal or domestic partner support (and any past-due support). The order tells the employer how much money to take out of the employee's pay check, how often to take out the money, and where to send it. This is also known as a wage assignment.
Get form FL-195
Effective: January 22, 2024
Go to
How-to instructions for Child Support
Go to
Child Support Form Packets
Go to
How-to instructions for Divorce
Go to
Divorce Form Packets
PDF Text:
Form Approved for Optional Use 
Judicial Council of California 
FL-195 [Rev. January 22, 2024]
INCOME WITHHOLDING FOR SUPPORT Family Code § 5208 
42 U.S.C. § 666(b)(6)(A)(ii) 
www.courts.ca.gov
FL-195
INCOME WITHHOLDING FOR SUPPORT
I. Sender Information: (Completed by the Sender) Date:
INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO
Child Support Agency (CSA) 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 ).  If you receive 
this document from someone other than a state or tribal CSA agency or a court, a copy of the underlying support order 
must be attached.  
State/Tribe/Territory Remittance ID (include w/payment)
City/County/Dist./Tribe Order ID 
Private Individual/Entity Case ID
II. Employer and Case Information: (Completed by the Sender)
Employer/Income Withholder's Name
Employer/Income Withholder's Address
Employer/Income Withholder's FEIN
RE: 
Employee/Obligor's Name (Last, First, Middle)
Employee/Obligor's Social Security Number
Employee/Obligor's Date of Birth
Custodial Party/Obligee’s Name (Last, First, Middle)
Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) 
III. Order Information: (Completed by the Sender)
This document is based on the support order from                                      (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? 
$ 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 . 
Yes No
IV. Amounts to Withhold: (Completed by the Sender)
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.
Document Tracking ID
OMB 0970-0154 
Expiration Date: 08/31/2026
Page 1 of 4

FL-195 [Rev. January, 22, 2024] INCOME WITHOLDING FOR SUPPORT (IWO)
FL-195
Employer/Income Withholder's Name: Employer/Income Withholder's FEIN:
Employee/Obligor's Name: SSN: 
Case ID: Order ID:
V. Remittance Information: (Completed by the Sender except for the "Return to Sender" check box.)
If the employee/obligor’s principal place of employment is (State/Tribe), you must begin withholding no
later than the first pay period that occurs days after the date of of the order/notice. Send payment
within business days of the pay date. If you cannot withhold the full amount of support for any or all orders for this
employee/obligor, withhold % of disposable income for all orders. If the employee/obligor’s principal place of
employment is not (State/Tribe), obtain withholding limitations, time requirements, the appropriate
method to allocate among multiple child support cases/orders, and any allowable employer fees from the jurisdiction of  
the employee/obligor’s principal place of employment.
State-specific withholding limit information is available at  
contacts-and-program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please
contact the tribe at or
.
You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act 
(CCPA) [15 USC § 1673 (b)]; or 2) the amounts allowed by the law of the state of the employee/obligor’s principal place of 
employment if the place of employment is in a state; or the tribal law of the employee/obligor’s principal place of 
employment if the place of employment is under tribal jurisdiction. The CCPA is available at
agencies/whd/fact-sheets/30-cppa. If the Order Information section does not indicate that the arrears are greater than 12 
weeks, then the employer should calculate the CCPA limit using the lower percentage.
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.
If the obligor is a nonemployee, obtain withholding limits from the Supplemental Information section in this IWO. This 
information is also available at 
requirements.
Remit payment to California State Disbursement Unit (SDU/Tribal Order Payee)
at P.O. Box 989067, West Sacramento, CA 95798-9067 (SDU/Tribal Payee Address)
Include the Remittance ID with the payment and if necessary this locator code of the SDU/Tribal order payee 
on the payment.
To set up electronic payments or to learn state requirements for checks, contact the State Disbursement Unit (SDU). 
Contacts and information are found at
Return to Sender (Completed by Employer/Income Withholder). Payment must be directed to an SDU in  
If Required by State or Tribal Law:
Signature of Judge/Issuing Official:
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.  
accordance with sections 466(b)(5) and (6) of the Social Security Act or Tribal Payee (see Payments in Section VI). 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. 
Page 2 of 4

FL-195 [Rev. January, 22, 2024] INCOME WITHOLDING FOR SUPPORT (IWO)
FL-195
Employer/Income Withholder's Name: Employer/Income Withholder's FEIN:
Employee/Obligor's Name: SSN: 
Case ID: Order ID:
VI. Additional Information for Employers/Income Withholders: (Completed by the Sender)
Priority: Withholding for support has priority over any other legal process under state law against the same income 
(section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender.
Payments: You must send child support payments payable by income withholding to the appropriate SDU or to a tribal 
CSA within 7 business days, or fewer if required by state law, after the date the income would have been paid to the 
employee/obligor and include the date you withheld the support from his or her income. You may combine withheld 
amounts from more than one employee/obligor’s income in a single payment as long as you separately identify each 
employee/obligor’s portion of the payment. Child support payments may not be made through the federal Office of Child 
Support Services (OCSS) Child Support Portal.
to provide information about employees who are eligible to receive lump sum payments and 
to provide contacts, addresses, and other information about their companies. Child support payments may not be made 
through the federal OCSS Child Support Portal.
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.
Supplemental Information:
Lump Sum Payments: You may be required to notify a state or tribal CSA of upcoming lump sum payments, such as 
bonuses, commissions, or severance pay, to this employee/obligor. Contact the sender to determine if you are required to 
report and/or withhold lump sum payments. Employers/income withholders may use the OCSS Child Support Portal 
Page 3 of 4

FL-195 [Rev. January, 22, 2024] INCOME WITHOLDING FOR SUPPORT (IWO)
FL-195
Employer/Income Withholder's Name: Employer/Income Withholder's FEIN:
Employee/Obligor's Name: SSN: 
Case ID: Order ID:
If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, you must 
promptly notify the CSA and/or the sender by returning this form to the address listed in the Contact Information section 
below or by using the OCSS Child Support Portal            Please report the new employer or income 
withholder, if known. 
VII. Notification of Employment Termination or Income Status: (Completed by the Employer/Income Withholder)
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 telephone number: 
Last known address:
Final payment date to SDU/Tribal Payee: Final payment amount:
New employer's or income withholder's name:
New employer's or income withholder's address:
VIII. Contact Information: (Completed by the Sender)
To Employer/Income Withholder:  If you have questions, contact (sender name) by
telephone: , by fax: , by email or website:
Send termination/income status notice and other correspondence to:
(sender address).
To Employee/Obligor: If the employee/obligor has questions, contact (sender name)
by telephone: , by fax: , by email or website:
IMPORTANT:  The person completing this form is advised that the information may be shared with the employee/obligor.
Encryption Requirements: 
When communicating this form through electronic transmission, precautions must be taken to ensure the security of the 
data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child 
Support Services. Other electronic means, such as encrypted attachments to emails, may be used if the encryption 
method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).
.
.
Page 4 of 4

Retrieval chunks

• #1

  Form ID: FL-195 Title: Income Withholding for Support Effective Date: 2024-01-22 Mandatory Form: no Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-195 Primary Download URL: https://www.courts.ca.gov/documents/fl195.pdf Form Detail Page: Income Withholding for Support (FL-195) Tells an employer that the…

• #2

  $ Per current child support $ Per past-due child support - Arrears greater than 12 weeks? $ 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 . Yes No IV. Amounts …

• #3

  employment if the place of employment is under tribal jurisdiction. The CCPA is available at agencies/whd/fact-sheets/30-cppa. If the Order Information section does not indicate that the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. If there is more…

• #4

  (section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender. Payments: You must send child support payments payable by income withholding to the appropriate SDU or to a tribal CSA within 7 business days, or fewer if required by state law, after the date the income wou…

• #5

  VII. Notification of Employment Termination or Income Status: (Completed by the Employer/Income Withholder) 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 employ…