Form JD-FM-150 "Case Input Record Non IV-D Income Withholding" - Connecticut

What Is Form JD-FM-150?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2014;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-150 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-FM-150 "Case Input Record Non IV-D Income Withholding" - Connecticut

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CASE INPUT RECORD
The Judicial Branch of the State of Connecticut complies
NON IV-D INCOME WITHHOLDING
with the Americans with Disabilities Act (ADA). If you need
Instructions
a reasonable accommodation in accordance with the
JD-FM-150 Rev. 4-14
1. See detailed instructions below.
ADA, contact a court clerk or an ADA contact person
listed at www.jud.ct.gov/ADA/.
C.G.S. § 52-362
2. Print legibly.
Judicial district
Court location (Number, street, town and zip code)
Docket number
Obligee (Person to Receive Money)
Obligor (Person to Pay Money)
q
q
Name (Last, first, middle initial)
Name (Last, first, middle initial)
Street
Street
City/Town
State
Zip code
City/Town
State
Zip code
Telephone number
Relationship to Obligor
Telephone number of Obligor
Telephone number of employer or payer of income
Social Security number (Required - see notice below)
Social Security number (Required - see notice below)
Sex
Sex
Date of birth
Date of birth
M
F
M
F
Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is
requested under sections 52-362 and 17b-179 of the Connecticut General Statutes. It will be used by the state child support
program to ensure the proper collection, verification and distribution of support under section 17b-179 of the Connecticut General
Statutes.
Child(ren)'s Name(s):
Child(ren)'s Name(s):
Date of Birth
Date of Birth
(As listed in support order)
(As listed in support order)
1.
5.
2.
6.
3.
7.
4.
8.
Print name
Date signed
Signed (Preparer)
Income withholding must be ordered in all child support cases. The Judicial District Clerk's Office will provide the required
forms. Once the income withholding of child support orders in Non IV-D cases starts, the withheld income of the obligor (the
person who owes the money) must be sent by the employer or payer of income to the State Disbursement Unit (not to the
obligee) which will send the money to the obligee. You do not have to pay for the administration of Non IV-D income
withholding. You must tell the Child Support Call Center of Support Enforcement Services (SES) if the obligor's
employer changes and about all changes/modifications to the income withholding, including orders to end the
income withholding. You must follow the instructions below whenever these types of changes occur. (SES will not
enforce your order unless you ask for full IV-D services. Full IV-D child support enforcement services are available to you
when you apply at a local office of the Department of Social Services. For more information about IV-D services, call the
Child Support Call Center at 1-800-228-KIDS (5437).)
Instructions
1. Fill out the top part of this form. Print legibly.
5. Keep a copy of all papers for your own records.
2. Get the Income Withholding for Support form (JD-FM-1) from the
6. If the obligor (person who owes money) did not file a written Appearance
Clerk's Office, Court Service Center or on the Judicial Branch website at
and an income withholding was ordered, you must fill out a Notice to
www.jud.ct.gov.
Nonappearing Obligor of Income Withholding Order (JD-FM-70) form
3. After you complete both forms, give the Income Withholding for Support
and have it served on the obligor. Attach proof that the JD-FM-70 was
(JD-FM-1) to the Clerk's Office for the clerk to review and sign.
served to a copy of the JD-FM-70 form and file it with the Clerk's Office.
4. After the Income Withholding for Support (JD-FM-1) is signed by the
7. If you have any questions about the income withholding, call Support
Clerk and returned to you, send it along with this form to Support
Enforcement Services (SES), Child Support Call Center at
Enforcement Services (SES), Child Support Call Center, P.O. Box 65,
1-800-228-KIDS (5437).
Vernon, CT 06066. This will allow SES to set up an account in the system
used to track child support payments. If you do not give both forms to
SES, the income withholding payments cannot be processed and
disbursed to you. SES will serve, or will make sure that the Income
Withholding for Support is served on the obligor's employer or payer of
income.
Distribution:
Original - SES
Copy - For Your Records
For Support Enforcement Services Only. Do not place this form in the court file.
Print Form
Reset Form
CASE INPUT RECORD
The Judicial Branch of the State of Connecticut complies
NON IV-D INCOME WITHHOLDING
with the Americans with Disabilities Act (ADA). If you need
Instructions
a reasonable accommodation in accordance with the
JD-FM-150 Rev. 4-14
1. See detailed instructions below.
ADA, contact a court clerk or an ADA contact person
listed at www.jud.ct.gov/ADA/.
C.G.S. § 52-362
2. Print legibly.
Judicial district
Court location (Number, street, town and zip code)
Docket number
Obligee (Person to Receive Money)
Obligor (Person to Pay Money)
q
q
Name (Last, first, middle initial)
Name (Last, first, middle initial)
Street
Street
City/Town
State
Zip code
City/Town
State
Zip code
Telephone number
Relationship to Obligor
Telephone number of Obligor
Telephone number of employer or payer of income
Social Security number (Required - see notice below)
Social Security number (Required - see notice below)
Sex
Sex
Date of birth
Date of birth
M
F
M
F
Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is
requested under sections 52-362 and 17b-179 of the Connecticut General Statutes. It will be used by the state child support
program to ensure the proper collection, verification and distribution of support under section 17b-179 of the Connecticut General
Statutes.
Child(ren)'s Name(s):
Child(ren)'s Name(s):
Date of Birth
Date of Birth
(As listed in support order)
(As listed in support order)
1.
5.
2.
6.
3.
7.
4.
8.
Print name
Date signed
Signed (Preparer)
Income withholding must be ordered in all child support cases. The Judicial District Clerk's Office will provide the required
forms. Once the income withholding of child support orders in Non IV-D cases starts, the withheld income of the obligor (the
person who owes the money) must be sent by the employer or payer of income to the State Disbursement Unit (not to the
obligee) which will send the money to the obligee. You do not have to pay for the administration of Non IV-D income
withholding. You must tell the Child Support Call Center of Support Enforcement Services (SES) if the obligor's
employer changes and about all changes/modifications to the income withholding, including orders to end the
income withholding. You must follow the instructions below whenever these types of changes occur. (SES will not
enforce your order unless you ask for full IV-D services. Full IV-D child support enforcement services are available to you
when you apply at a local office of the Department of Social Services. For more information about IV-D services, call the
Child Support Call Center at 1-800-228-KIDS (5437).)
Instructions
1. Fill out the top part of this form. Print legibly.
5. Keep a copy of all papers for your own records.
2. Get the Income Withholding for Support form (JD-FM-1) from the
6. If the obligor (person who owes money) did not file a written Appearance
Clerk's Office, Court Service Center or on the Judicial Branch website at
and an income withholding was ordered, you must fill out a Notice to
www.jud.ct.gov.
Nonappearing Obligor of Income Withholding Order (JD-FM-70) form
3. After you complete both forms, give the Income Withholding for Support
and have it served on the obligor. Attach proof that the JD-FM-70 was
(JD-FM-1) to the Clerk's Office for the clerk to review and sign.
served to a copy of the JD-FM-70 form and file it with the Clerk's Office.
4. After the Income Withholding for Support (JD-FM-1) is signed by the
7. If you have any questions about the income withholding, call Support
Clerk and returned to you, send it along with this form to Support
Enforcement Services (SES), Child Support Call Center at
Enforcement Services (SES), Child Support Call Center, P.O. Box 65,
1-800-228-KIDS (5437).
Vernon, CT 06066. This will allow SES to set up an account in the system
used to track child support payments. If you do not give both forms to
SES, the income withholding payments cannot be processed and
disbursed to you. SES will serve, or will make sure that the Income
Withholding for Support is served on the obligor's employer or payer of
income.
Distribution:
Original - SES
Copy - For Your Records
For Support Enforcement Services Only. Do not place this form in the court file.
Print Form
Reset Form