HCCSNTE181130 REQUEST FOR NOTICE TO EMPLOYER OF INCOME WITHHOLDING EMAIL: BILLING@HCDISTRICTCLERK.COM FAX: 832-927-0135 MAIL: MARILYN BURGESS, DISTRICT CLERK ATTENTION: WAGE ASSIGNMENT DEPARTMENT POST OFFICE BOX 4651 HOUSTON, TEXAS 77210 SUBMIT $15 PER REQUEST (IF MULTIPLE ORDERS ARE INDICATED, A $15 FEE WILL APPLY PER ORDER) WE ACCEPT PAYMENT BY MAIL VIA CASHIER CHECK OR MONEY ORDER CREDIT CARD PAYMENTS SHALL BE COMPLETED ONLINE OR IN PERSON AT 201 CAROLINE, ROOM 170, HOUSTON, TX 77002. WE DO NOT ACCEPT COMPANY CHECKS OR PERSONAL CHECKS HARRIS COUNTY CAUSE NUMBER: IN THE DISTRICT COURT STYLE: VS. DATE WAGE WITHHOLDING ORDER SUBMITTED TO COURT OR SIGNED BY JUDGE: NOTICE: IF ORDER IS NOT SIGNED WITHIN 10 BUSINESS DAYS FROM THE DATE THIS REQUEST WAS PROCESSED, NOTICE WILL BE CANCELLED AND FUNDS REFUNDED TO THE APPLICANT OR NAME ON CARD IF DIFFERENT. SPECIFY ORDER TYPE CHILD SUPPORT SPOUSAL SUPPORT MEDICAL SUPPORT ATTORNEY FEES TERMINATION OF GARNISHMENT NOTICE OF ASSIGNMENT INFORMATION EMPLOYEE NAME: COMPANY PAYROLL OR HUMAN RESOURCE DEPARTMENT MAILING ADDRESS: ATTN: PHONE # ADDRESS: CITY: STATE: ZIP: APPLICANT SBN/LFI: ADDRESS: CITY: STATE: ZIP: PHONE NUMBER: EMAIL ADDRESS: @ WHEN PAYING BY CREDIT CARD, YOU WILL BE CONTACTED WITH FURTHER INSTRUCTIONS TO COMPLETE THE PAYMENT PROCESS. *****EFILING Users: Complete payment via online provider ***** FOR DISTRICT CLERK OFFICE USE ONLY TRANSACTION NO: RECIEPT NO: American LegalNet, Inc. www.FormsWorkFlow.com