Fill and Sign the Employer and Tax Information Texas Secretary of State

ATTORNEY (Name, state bar number, and address) : TELEPHONE NO.: FAX NO.: ATTORNEY FOR STATE TAX AGENCY APPLICATION OF (Name): TAXPAYER/RESPONDENT TEMPORARY EARNINGS WITHHOLDING ORDER FOR TAXES TAX AGENCY NUMBER: NAME OF STATE TAX AGENCY: TO EMPLOYER 1. Employer (name and address) : 2. Employee (name and address): 4. This order expires 15 days after service on the employer, or upon order of the court, whichever occurs first, unless extended by court order. 5. DELIVER ONE COPY OF THIS ORDER TO THE EMPLOYEE IMMEDIATELY. Date: (TYPE OR PRINT NAME AND TITLE) (SIGNATURE) IMPORTANT NOTICE TO TAXPAYER/EMPLOYEE A. Your employer is required to withhold from your earnings all sums necessary to m eet the tax liability shown in item 3a and pay them to the tax agency shown above. B. This Temporary Earnings Withholding Order will expire 15 days after service upon your employer, unless it is extended by the court. This form is served in duplicate on the employer. EMPLOYER: DELIVER ONE COPY TO THE EMPLOYEE, AND COMPLETE THE EMPLOYER’S RETURN AND MAIL IT TO THE STATE TAX AGENCY NOTED ABOVE. Form Adopted for Mandatory Use Judicial Council of California WG-024 [Rev. January 1, 2007] TEMPORARY EARNINGS WITHHOLDING Code of Civil Procedure, § 706.076 ORDER FOR TAXES (Wage Garnishment-Sta te Tax Liability) 3. You are directed to withhold from the employee’s earnings and retain in your possession or control all disposable earnings now due the employee or that become due within 15 days after this order is served on you, as follows: a. Employee’s tax liability: $ b. Total to be withheld: $ C. The State will apply to the court for an Earnings Withholding Order for Taxes directing your employer to continue to withhold money from your earnings. You will receive additional information on how to file a Claim of Exemption and when and where to appear for a court hearing. WG-024 Page 1 of 1