Fillable Payment History Request Form - Child Support Department printable pdf download

Payment History Request Form - Child Support Department

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Payment History Request

Chris Daniel, Harris County District Clerk

Child Support Department

This request is for cases prior to the establishment of the State Disbursement Unit (Year 2004). The

payment record reflects non-custodial parent payments received by the Harris County Child Support

Registry. You may need to contact the Office of the Attorney General for payments received after the

State Disbursement Unit (SDU) was established to ensure a complete record is obtained for the

specified case/cause number.

HARRIS COUNTY CAUSE NO_________________

IN THE ________ DISTRICT COURT

(If cause number not provided, $5 search fee is applied) (51.318(b)(3) Gov’t Code)

STYLE: ______________________________ VS. ______________________________

MAIL TO:

CHRIS DANIEL, DISTRICT CLERK

ATTENTION: CHILD SUPPORT DEPARTMENT

POST OFFICE BOX 4651

HOUSTON, TEXAS 77210

FAX TO:

(713) 755-4359

EMAIL TO:

CUSTOMER NAME: (Last, First, Middle)

_____________________________________________________________________________________

CUSTOMER TELEPHONE NUMBER: ____________________________________________________

CUSTOMER ADDRESS: _______________________________________________________________

CITY: _________________________________

STATE: _____

ZIP: ________________________

$1/page (51.318(b)(11) Gov’t Code)

HARRIS COUNTY CHILD SUPPORT PAYMENT HISTORY

How many copies? ___ (Certified at no additional charge)

Mail (Applicable Postage and Handling fees will be charged)

___

Request will be sent to address provided above.

___ Fax Express Return

Fax Number: _________________________________

* 4% Convenience fee of total cost will be applied when request is received by mail or fax.

I hereby authorize the Harris County District Clerk to charge my credit card for payment of the

services requested above:

Select One)

CREDIT CARD # _________________________________ EXPIRATION DATE: __________

NAME PRINTED ON CREDIT CARD:

______________________________________________________________________________

CREDIT CARDHOLDER ADDRESS (if different than above):

______________________________________________________________________________

AUTHORIZED SIGNATURE:

______________________________________________________________________________

FOR DISTRICT CLERK CHILD SUPPORT OFFICE USE ONLY

TRANSACTION NO: ________________________ RECIEPT NO: ______________________

HCCSPH160210

Payment History Request Form - Child Support Department

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