Free Income Withholding Request for Notice to Employer.PDF - Texas

REQUEST FOR NOTICE TO EMPLOYER OF INCOME WITHHOLDING

PAYMENT OF $15.00 MUST BE SUBMITTED WITH THIS FORM AS FEE FOR THE FOREGOING REQUEST. WE ACCEPT PAYMENT BY CASHIER CHECKS, MONEY ORDERS OR CREDIT CARDS. IF PAYING BY CREDIT CARD, INCLUDE THE TYPE OF CREDIT CARD, CREDIT CARD NUMBER, AND EXPIRATION DATE WITH YOUR REQUEST. ***We do not accept company checks or personal checks***
TO: LOREN JACKSON, DISTRICT CLERK POST OFFICE BOX 4651 HOUSTON, TEXAS 77210 ATTENTION: FAMILY INTAKE DEPARTMENT I REQUEST THAT A NOTICE OF ASSIGNMENT OF INCOME BE ISSUED FOR: CAUSE NUMBER: ___________________________ IN THE __________ DISTRICT COURT

STYLE: _________________________________ vs. _____________________________________ NAME OF EMPLOYER WHICH ASSIGNMENT IS TO BE ISSUED TO: __________________ ___________________________________________________________________________________ ___________________________________________________________________________________ MAILING ADDRESS FOR EMPLOYER'S PAYROLL OR HUMAN RESOURCE DEPARTMENT:
___________________________________________________________________________________________________ ___________________________________________________________________________________________________

The employer of: ___________________________________________________________________
(PAYOR)

Assignment of Wage Order was signed on ______________________________________________
(DATE)

Assignment of Wage Order NOT signed; submitted to Court on ____________________________
(DATE)

************************************************************************************* Applicant's Name: __________________________________________________________________ Telephone Number: _________________________________________________________________ Address: ___________________________________________________________________________ ___________________________________________________________________________________
S:\FormsLib\Civil Bureau\Civ Fam Intake & Customer Svc\Famintake\ Income Withholding, Request for Notice to Employer Revised 10/15/98