FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT CHAPTER 1240-2-2 (Rule 1240-2-2-.06) STATE OF TENNESSEE NOTICE OF ISSUANCE OF INCOME ASSIGNMENT DUE TO DELINQUENCY You are hereby notified pursuant to T.C.A. §36-5-501(b)(2) that due to a delinquency in your child support payments in the amount of $__________ as of the _____ day of __________, ______, 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 income payable to you to satisfy your support obligation in the amounts and for the purposes shown in the attached Order/Notice to Withhold Income for Child Support (Order for Income Assignment). Your total arrearage as of the ______ day of ___________, ______, is $ _________ plus twelve (12%) per annum simple interest. You may contest this Notice of Income Assignment by filing a written request for a hearing with ___________________________________ 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. 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. CERTIFICATE OF SERVICE I hereby certify that a copy of this NOTICE OF ISSUANCE OF INCOME ASSIGNMENT DUE TO DELINQUENCY was served on the Respondent by delivering to him/her by on this the _______________ day of __________________, ______. _____________________________________ 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. Amendment filed August 17, 2005; effective October 31, 2005. October, 2005 (Revised) 1 American LegalNet, Inc. www.USCourtForms.com