REQUEST FOR ISSUANCE OF CHILD SUPPORT WITHHOLDING ORDER FC 158.104 NOTICE: REQUEST MUST BE COMPLETED AND DELIVERED TO THE DISTRICT CLERK TO ACTIVATE THE WITHHOLDING ORDER ALONG WITH A $15.00 FILING FEE. CAUSE NO. ___________, STYLE OF CASE: ____________________________________________________________ ___________________________________________________________________________ OBLIGOR :________________________________ SOC.SEC #__________________________ ADDRESS:____________________________________________________________________ CITY, STATE, ZIP:______________________________________________________________ OBLIGEE:_________________________________ SOC.SEC #__________________________ ADDRESS:____________________________________________________________________ CITY, STATE, ZIP: ______________________________________________________________ EMPLOYER'S NAME: ____________________________________________________________ ADDRESS: ____________________________________________________________________ CITY, STATE, ZIP:_______________________________________________________________ ATTENTION : __________________________________________________ PAYROLL CLERK PHONE: _______________________________ INFORMATION FURNISHED BY: _____________________________________________________________________________ ADDRESS:__________________________CITY, STATE, ZIP____________________________ SIGNATURE: _________________________________ or Attorney ______________________________________ Applicant DATE REQUESTED: ____________________________ 20______ American LegalNet, Inc. www.FormsWorkFlow.com