SECTION 1 – Employee Information
Employee Name:	Date:
SECTION 2 – Employee Disclosure
This is to certify that:
I do not, at present, have a child support withholding order.
I do, at present, have a child support withholding order.
DCSE Identification Number:
Employee Name (Print)	Employee Signature	Date
House Bill No. 2046 Section 60.2-114.1 Notification of Withholding Order – When an individual is hired for employment, the employer shall, at the time of the initial hiring, request that the employee disclose whether he has an income withholding order pursuant to Section 20-79.1 or Section 63.2-1924. When an employee discloses that he owes child support that is required to be withheld, the employer shall begin withholding according to the terms of the order. Information disclosed under this section shall not be divulged except to the extent necessary for the administration of the child support enforcement program or when otherwise authorized by law. (offered January 19, 2018)