Request For Notice To Employer Of Income Withholding Form
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1REQUEST FOR NOTICE TO EMPLOYER
OF INCOME WITHHOLDING
MAIL TO:
CHRIS DANIEL, DISTRICT CLERK
POST OFFICE BOX 4651
HOUSTON, TEXAS 77210
ATTENTION: WAGE ASSIGNMENT DEPARTMENT
OR FAX TO:
713-755-4359
SUBMIT $15 PER REQUEST
(IF MULTIPLE ORDERS ARE INDICATED, A $15 FEE WILL APPLY PER ORDER)
WE ACCEPT PAYMENT BY CASHIER CHECK, MONEY ORDER, OR CREDIT CARD
WE DO NOT ACCEPT COMPANY CHECKS OR PERSONAL CHECKS
HARRIS COUNTY CAUSE NUMBER: _____________________________ IN THE ________ DISTRICT COURT
STYLE: ________________________________________ VS. ____________________________________________
DATE WAGE WITHHOLDING ORDER SUBMITTED TO COURT OR SIGNED BY JUDGE: _______________
NOTICE: IF ORDER IS NOT SIGNED WITHIN 10 BUSINESS DAYS FROM THE DATE THIS REQUEST WAS PROCESSED,
NOTICE WILL BE CANCELLED AND FUNDS REFUNDED TO THE APPLICANT OR NAME ON CARD, IF DIFFERENT.
SPECIFY ORDER TYPE
___ CHILD SUPPORT
___ SPOUSAL SUPPORT
___ MEDICAL SUPPORT
___ ATTORNEY FEES
___ TERMINATION OF GARNISHMENT
NOTICE OF ASSIGNMENT INFORMATION
EMPLOYEE NAME: ____________________________________________________________________________
(OBLIGOR’S NAME)
COMPANY’S NAME:
___________________________________________________________________________________
COMPANY PAYROLL OR HUMAN RESOURCE DEPARTMENT MAILING ADDRESS:
ATTN: _______________________________________________ PHONE # _________________________________
ADDRESS: _____________________________________________________________________________________
CITY: _______________________________
STATE: ___________________
ZIP: ___________________
APPLICANT’S NAME: ________________________________________ SBN/LFI# __________________________
TELEPHONE NUMBER (S): _______________________________________________________________________
ADDRESS: _____________________________________________________________________________________
CITY: _________________________________ STATE: _____________________
ZIP: ___________________
***** EFILING Users: DO NOT include credit card information on this form - enter via online provider. *****
ALL OTHERS PLEASE COMPLETE THE FOLLOWING IF PAYING BY CREDIT CARD*:
NAME PRINTED ON CARD: _____________________________ _________________________________________
CARD TYPE: __ Visa __ MasterCard __ AmEx __Discover (Select One)
CREDIT CARD # ________________________________________ EXPIRATION DATE: _____________________
BILLING ADRESS (If different from Applicant’s)_______________________________________________________
BILLING PHONE (If different from Applicant’s)________________________________________________________
AUTHORIZING SIGNATURE: _____________________________________________________________________
* 4% Convenience fee of total cost will be applied if received by mail or fax.
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