Request For Notice To Employer Of Income Withholding
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1
2REQUEST 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: CHRIS DANIEL, 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
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Parent category: Financial