FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.12) STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES NOTICE OF MODIFICATION OF INCOME ASSIGNMENT TO: FROM: ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ MAILING DATE OF NOTICE: ___________________________________ Pursuant to a court order, statutory requirements directing payment by Order/Notice to Withhold Income for Child Support (Order for Income Assignment), or administrative actions by the Department of Human Services, you have been ordered to pay your child support obligation by means of an income assignment. This is to notify you that the original Order/Notice to Withhold Income for Child Support (Order for Income Assignment) has been modified and that your employer, or other person, corporation, or institution which is a payer of income has been directed, pursuant to Tennessee Code Annotated, §36-5-501, to withhold a greater or lesser amount of income payable to you to satisfy your support obligation. Your income assignment has been modified in the following manner: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ You may contest this Notice of Modification Income Assignment by filing a written request for an administrative hearing with the Local Child Support Office at the address above within fifteen (15) days of the mailing of this notice as noted above. The grounds for contesting the Notice are that the income withholding is improper due to a mistake of fact, or the amount withheld is improper due to a mistake of fact. If you contest this Notice of Income Assignment within the above time limit, a hearing will be promptly set. Your employer will continue to withhold income unless a decision favorable to you is rendered. You and your employer will be notified of the decision within forty-five (45) days of the date the Order/Notice to Withhold Income for Child Support (also called an Order for Income Assignment or Income Assignment) was issued. If an unfavorable decision is rendered, you have a right to further appeal the decision as described in the Department’s hearing order following the decision. It is your responsibility to keep the Court Clerk and the Local Child Support Office informed of the name and address of your current employer, whether you have access to health insurance coverage, and if so, the health insurance policy information. You must also immediately notify the Court Clerk and the Local Child Support Office of any changes in, or any additional employment, including the name and address of the new employer. Your new employer will be notified of the Order for Income Assignment. An Order for Income Assignment shall be mandatory as long as current support or arrearages are still owed. Clerks of court are authorized to issue an Order for Income Assignment to the employer or payer of income of the obligor and to institute the process to assign income when the obligor fails to pay court costs, but shall not have priority over the Order for Income Assignment for child or spousal support. October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.12, continued) Authority: T.C.A. §§ 4-5-202, 8-21-403, 36-5-116, 36-5-501, and 71-1-132(c); 42 U.S.C. §§ 651 et seq., 42 U.S.C. §§ 652(a)(11), 654(9)(E), 654a(g)(1)(A)(ii), 654b(a), and 666(a)(8) and (b); 45 C.F.R. §§ 303.6(c)(1), 303.7, and 303.100; and United States Department of Health and Human Services Office of Child Support Enforcement Action Transmittal 04-05 (July 15, 2004). Administrative History: Original rule filed October 14, 1999; effective December 28, 1999. Public necessity rule filed May 20, 2005; effective through November 1, 2005. Amendments filed August 17, 2005; effective October 31, 2005. October, 2005 (Revised) 2 American LegalNet, Inc. www.USCourtForms.com