Request for Issuance of Employers Order to Withhold


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(Name, Address, and Phone Number of Person Making Request) 
 
NAME:  ______________________________________________________________________ 
 
STREET ADDRESS:  ___________________________________________________________ 
 
CITY: __________________ STATE: ____ ZIP CODE: ________ PHONE #: ______________ 
 
CAUSE NUMBER:  _______________ 
 
IN THE MATTER OF:    IN THE ____________ JUDICAL 
 
________________________________  DISTRICT COURT OF 
AND 
       DALLAS COUNTY, TEXAS 
_________________________________   
 
REQUEST FOR ISSUANCE OF EMPLOYERS ORDER 
TO WITHHOLD INCOME OR WRIT TO WITHHOLD INCOME 
 
To the Clerk of the Court: 
 
Pursuant to chapter 158.104 and 158.105 of the Texas Family Code, request is hereby made that 
you issue a certified copy of the Employer’s Order to Withhold Income or Writ to Withhold 
Income, and a copy of Subchapter C of the Texas Family Code to: 
 
 Obligor’s Employer: ______________________________________________________ 
 
 Address: ________________________________________________________________ 
 
 City: ______________________________ State: _________ Zip: __________________ 
 
 Attn: ________________________ Phone #: ________________ Fax #: _____________ 
 
 
Current or last known address of Oblige:  Current or last known address of Obligor: 
  
Address: _______________________________  Address: ___________________________________ 
 
City:________________ State:____ Zip:______  City:__________________ State:____ Zip:________ 
 
 
 
     By: _______________________________________ Date: _________ 
 
 
Mail Request to:    Felicia Pitre, District Clerk 
   Attn: Civil/Family File Desk 
   600 Commerce St., 
   Dallas, Texas 75202 
 
With a conformed (signed) copy of the Employer’s Order to Withhold, a $15.00 personal check, cahiers check, 
business check or money order (you must have driver’s license or state identification number on your check) 
payable to: Felicia Pitre, District Clerk.