REQUEST FOR ISSUANCE OF 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: ______________________________________ VS. _______________________________________ OBLIGOR :________________________________ SOC.SEC #__________________________ ADDRESS:____________________________________________________________________ OBLIGEE:_________________________________ SOC.SEC #__________________________ ADDRESS:____________________________________________________________________ EMPLOYER'S NAME ____________________________________________________________ EMPLOYER'S PHONE NUMBER:__________________________________________________ ATTENTION : _________________________________________________ METHOD OF DELIVERY (Select One) E-Mail_____ Fax____ E-Mail Address:_______________________________ Fax Number: Area Code (______) __________________________ INFORMATION FURNISHED BY:__________________________________________________ ADDRESS:_________________________________________PHONE:(____)_______________ REQUESTED BY: Obligor / Obligee; Friend of the Court; Attorney; Friend of the Court; Title IV-D Agency (circle one) SIGNATURE: _______________________________________ DATE__________________ 20______ ORIG COPY: case file American LegalNet, Inc. www.FormsWorkFlow.com