PAYROLL DEDUCTION REQUEST Please complete the following form so that we may execute a payroll deduction for your Child Support Obligation. You MUST sign up for the amount you are court ordered to pay; if you erroneously sign up for too little, we will automatically modify this payroll deduction request to meet your obligation amount. Date: Case Number: ABOUT YOU... Your Name: SS Number: Address: City: Zip Code: Phone Number: State: Date of Birth: ABOUT YOUR EMPLOYER... Full Company Name: Business Address: City: Zip Code: Payroll Contact Person: (If Known) Payroll Cycle: (e.g. weekly, bi-weekly, monthly) State: Business Phone Number: ABOUT YOUR DEDUCTION REQUESTED... Court Ordered Obligation: Deduction Amount Requested: per per per Please indicate the amount to be applied towards arrearages, if any: Do you wish for this to continue when arrearages are satisfied? Yes No Should you be requesting an amount higher than your court ordered obligation which is NOT being applied to arrearages, please indicate below a brief statement of your intention for submitting this higher amount: SIGNATURE: I certify that the above information is true and correct THIS DEDUCTION WILL TRANSFER TO ANY FUTURE EMPLOYERS UNLESS THE AGENCY IS OTHERWISE NOTIFIED, CSEA-028 American LegalNet, Inc. www.USCourtForms.com