Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice To Obligor Of Issuance Of Income Assignment Form. This is a Tennessee form and can be use in Parenting Plan Statewide.
Loading PDF...
Tags: Notice To Obligor Of Issuance Of Income Assignment, Tennessee Statewide, Parenting Plan
FORMS FOR WITHHOLDING OF INCOME FOR CHILD SUPPORT
CHAPTER 1240-2-2
(Rule 1240-2-2-.07)
STATE OF TENNESSEE
DEPARTMENT OF HUMAN SERVICES
NOTICE OF ISSUANCE 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 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).
You may contest this Notice of 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.
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