NOT TICE: DOCU UMENT CO ONTAINS SE ENSITIVE DATA D J O H N D . K I N A RD R DISTRICT CLERK GALVESTON CO D T G OUNTY REQUES FOR NOTICE T EMPLO ST TO OYER TO WITHH O HOLD INC COME FR ROM EAR RNINGS Date of Request: Case Number: Nam of Payor/ Employee: me E Last 4 Digits of So ocial Security No. of Employee: y Empl loyer's Name e: Atten ntion: loyer's Mailin Address: Empl ng City: : State: Zip Code: XX XX XX Court Number: t PER RSON RECEI IVING THE SUPPORT PAYMENT E Nam Payee: me Paye Mailing Address: ee's A City State: Zip Code Requ uesting Party Name: N Signa ature of Requ uesting Party: Addr of Reque ress estor: City: : Phon (Work): ne State: Phone (H Home): SERVICE WILL BE ISSUE UPON PAYM B U MENT OF TH $15.00 FE HE EE (TO BE COMPL LETED BY CLERK) C Date $15.00 fee was paid: e w Issue by: ed Deputy Clerk Zip Code: American LegalNet, Inc. www.FormsWorkFlow.com