Fill and Sign the Request for Notice to Employer Esquire Legal Form

HCCSNTE 111417 REQUEST FOR NOTICE TO EMPLOYER OF INCOME WITHHOLDING MAIL TO: CHRIS DANIEL , DISTRICT CLERK POST OFFICE BOX 4651 HOUSTON, TEXAS 77210 ATTENTION: WAGE ASSIGNMENT DEPARTMENT OR FAX TO: 832 -927 -0135  SUBMIT $15 PER REQUEST (IF MULTIPLE ORDERS ARE INDI CATED , A $15 FEE WILL APPLY PER ORDER)  WE ACCEPT PAYMENT BY CASHIER CHECK, MONEY ORDER , OR CREDIT CARD  WE DO NOT ACCEPT CO MPANY 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 WA S 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: ____________________________________________________________________________ (OBLIGOR’S NAME) COMPANY’S NAME: ___________________________________________________________________________________ COMPANY PAYROLL OR HUMAN RES OURCE DEPARTMENT MAILING ADDRESS: ATTN: _______________________________________________ PHONE # _________________________________ ADDRESS: _____________________________________________________________________________________ CITY: _________________________ ______ STATE: ___________________ ZIP: ___________________ APPLICANT ’S NAME: ______________ __________________________ SBN/LFI# __________________________ TELEPHONE NUMBER (S): _______________________________________________________________________ ADDR ESS: _____________________________________________________________________________________ CITY: _________________________________ STATE: _____________________ ZIP: ___________________ ***** EFILING Users : DO NOT include credit card informatio n on this form - enter via online provider. ***** ALL OTHERS PLEASE COMPLETE THE FOLLOWING IF PAYING BY CREDIT CARD *: NAME PRINTED ON CARD: _____________________________ _________________________________________ CARD TYPE: __ Visa __ MasterCard __ AmE x __Discover (Select One ) CREDIT CARD # ________________________________________ EXPIRATION DATE: _ ________ ___________ _ BILLING ADRESS (If different from Applicant’s)_______________________________________________________ BILLING PHONE (If different from Applicant’s)__ ______________________________________________________ AUTHORIZING SIGNATURE: _____________________________________________________________________ * 4% Convenience fee of total cost will be applied if received by mail or fax .