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ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT
(ADMINISTRATIVE WRIT OF WITHHOLDING)
Original Amended Termination
State of Texas
Co./City/Dist. of TARRANT COUNTY
Tribunal/Case Number 231-331746-02
Employer's/Withholder's Name Child(ren)'s Name(s) DOB SSN
JACKSON CONSTRUCTION
CASANDRA MARIE PUGA 02/02/00 631-70-1849
Employer's/Withholder's Address
5112 SUN VALLEY
FORT WORTH, TX 76119
Employer/Withholder's Federal EIN Number:
RE: PUGA, JAVIER
Employee's/Obligor's Name (Last, First, MI)
Employee's/Obligor's Social Security Number 634-80-2224
Employee's/Obligor's Case Identifier 0009519259
PUGA, CINDY ANN
Obligee Name (Last, First, MI)
If checked, you are required to enroll the child(ren) indentified above in any health insurance coverage available to the
employee's/obligor's through his/her employment.
ORDER INFORMATION: This Order/Notice is based on the support order from TX.
You are required by law to deduct these amounts from the employee's/obligor's income until further notice.
$ 276.00 monthly current child support
$ 90.00 monthly past-due child support - Arrears 12 weeks or greater? Yes No
$ 0.00 monthly current medical support
$ 0.00 monthly past-due medical support
$ spousal support
$ other (specify) __________________________
for a total of $
366.00 monthly to be forwarded to the payee below.
You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered
payment cycle, withhold one of the following amounts:
$ 84.46per weekly pay period. $ 183.00per
semimonthly pay period (twice a month).
$ 168.92per biweekly pay period(every two weeks). $ 366.00per
monthly pay period.
REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If
the employee's/obligor's principal place of employment is Texas, begin withholding no later than the first pay period following
the date on which this Order/Notice was delivered to the employer. Send payment on the same day of the pay date/date of
withholding. The total withheld amount, including your fee, cannot exceed 50% of the employee's/obligor's aggregate disposable
weekly earnings.
If the employee's/obligor's principal place of employment is not Texas, for limitations on withholding, applicable time
requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's principal place of
employment (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS).
If remitting payment by EFT/EDI, call _____________ before first submission. Use this FIPS code: ____________________
Bank routing code: ____________________ Bank account number _______________.
Make check payable to (Payee and Case Identifier): Send check to: TX CHILD SUPPORT SDU
P O BOX 659791
ATTORNEY GENERAL OF TEXAS
AG Case # 0009519259
Cause # 231-331746-02 SAN ANTONIO TX 78265-9791
PIN #
Authorized by Print Name and Title: Deputy Attorney General for Child Support State of Texas Date: 03/23/2004
IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. OMB: 0970-0154
December 2002 Form 3N001
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is
different from the state that issued this order, a copy must be provided to your employee even if the box is not checked.
1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned
businesses located on a reservation that choose to withhold in accordance with this notice.
2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same
income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please
contact the State Child Support Enforcement Agency or party listed in number 12 below.
3. Combining Payments: You can combine withheld amounts from more than one employee's/obligor's income in a single
payment to each agency/party requesting withholding. You must, however, separately identify the portion of the
single payment that is attributable to each employee/obligor.
4. Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The
paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with
the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you
must implement the withholding order and forward the support payments.
5. Employee/Obligor with Multiple Support Withholdings. If there is more than one Order/Notice to Withhold Income for Child
Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State
withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor
all Order/Notices to the greatest extent possible. (See #10 below.)
6. Termination Notification: You, JACKSON CONSTRUCTION must promptly notify the Child Support Enforcement Agency
or payee
when the employee/obligor no longer works for you. Please provide the information requested and return a complete
copy of this order/notice to the Child Support Enforcement Agency or payee.
EMPLOYEE'S/OBLIGOR'S NAME: JAVIER PUGA CASE IDENTIFIER: AG.No 0009519259
DATE OF SEPARATION FROM EMPLOYMENT: ____________________________________________________________
LAST KNOWN HOME ADDRESS: __________________________________________________________________________
NEW EMPLOYER/ADDRESS: ______________________________________________________________________________
7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions,
or severance pay. If you have any questions about lump sum payments, contact the person or authority below.
8. Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. If you fail
to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld
from the employee's/obligor's income and any other penalties set by State law.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
9. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support
withholding.
10. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit
Protection Act(15 U.S.C. § 1673(b)); 2) the amounts allowed by the State of the employee's/obligor's principal place of
employment. The Federal limit applies to the aggregate disposable weekly earnings(ADWE). ADWE is the net income left
after making mandatory deductions such as: State,Federal,local taxes, Social Security taxes,statutory pension
contribution, and Medicare taxes.
Additional Information:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
11. Submitted by AMANDA J BYERLY
Attorney General of Texas
CHILD SUPPORT UNIT 0402E
6100 WESTERN PLACE #405
FT WORTH, TX 76107
12. If you or your employee/obligor have any questions, contact: AMANDA J BYERLY
by telephone at (817) 731-9811 or by FAX at (817) 731-9239
or by Internet__________________________________________________________________________.
IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. OMB: 0970-0154
December 2002 Form 3N001
NCP Name: JAVIER PUGA
CP Name: CINDY ANN PUGA
OAG Number: 0009519259
CAUSE NUMBER 231-331746-02
IN THE INTEREST OF § IN THE 231ST DISTRICT COURT
§
CASANDRA MARIE PUGA §
§ OF
§
§
§ TARRANT COUNTY , TEXAS
§
NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING
JAVIER PUGA , Obligor, is hereby given notice pursuant to Texas Family Code Chapter 158, Subchapter F, that his
employer is immediately required to withhold the amounts specified below for payment of his current support and periodic
medical support obligation, and for any overdue support arrearage, as follows:
OBLIGOR: JAVIER PUGA OBLIGEE: CINDY ANN PUGA
SSN: 634-80-2224 SSN: 454-57-2778
Obligor's Employer: JACKSON CONSTRUCTION
5112 SUN VALLEY
FORT WORTH, TX 76119
CHILDREN
Name Sex DOB SSN DL# Birthplace
CASANDRA MARIE PUGA F 02/02/00 631-70-1849 N/A FT WORTH TX
Current Support Due: $ 276.00 monthly
Periodic Medical Support Due: $ 0.00 monthly
Total Arrearage, including
$ 71.54 accrued interest: $ 3,576.09
As of: 03/23/2004
Amounts to be withheld from Obligor's wages upon service of Writ:
On Current Support: $ 276.00 monthly
On Periodic Medical Support $ 0.00 monthly
On Arrearage Owed: $ 90.00 monthly
NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING Page 1
June 2001 Form 3W001
RIGHTS AND PROCEDURES
Attached to this notice is a copy of the Administrative Writ of Withholding issued in this matter.
JAVIER PUGA, may contest withholding on the grounds that the identity of the Obligor or the existence or amount of
arrearages is incorrect by requesting a review by the Title IV-D agency, by telephone conference or in person, at the
telephone number and address below:
(817) 731-9811
The Office of the Attorney General
CHILD SUPPORT UNIT 0402E
6100 WESTERN PLACE #405
FT WORTH, TX 76107
After a review, the Title IV-D agency may continue the attached writ in effect or may issue a new administrative writ
modifying the amount to be withheld or terminating withholding.
If a review fails to resolve any issue in dispute, the obligor may file a motion with the court to withdraw the
administrative writ and request a hearing with the court not later than the 30th day after receiving notice of the agency's
determination. Income withholding may not be interrupted pending a hearing by the court.
Should a Motion to Withdraw be filed, and a hearing conducted, the court will be requested to confirm all arrearage
amounts then due.
If this is a reissuance of an existing withholding order on file with the court of continuing jurisdiction and the amount to
be withheld for an arrearage is not being adjusted, pursuant to Texas Family Code §158.502, the preceding right and
procedures regarding contests, reviews and judicial intervention into this administrative withholding process do not apply.
AMANDA J BYERLY
Child Support Officer
Child Support Division
CHILD SUPPORT UNIT 0402E
6100 WESTERN PLACE #405
FT WORTH, TX 76107
Telephone No. (817) 731-9811
Fax No. (817) 731-9239
CERTIFICATE OF NOTICE
I certify a copy of this Notice of Administrative Writ of Withholding was mailed by first class to Obligor and Obligee on
03/24/04 pursuant to Texas Family Code §158.505.
Cynthia Bryant
Deputy Attorney General for Child Support
NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING Page 2
June 2001 Form 3W001
MC: NM 0402E
Bar Code Area 115973366
FS#: 115973366
Central File Maintenance
P.O. Box 12048
AUSTIN, TX 78711-2048
100 N HOUSTON ST Date: 03/24/04
Custodial Parent: CINDY PUGA
FORT WORTH, TX 76196 Non-Custodial Parent: JAVIER PUGA
Attorney General Case #: 0009519259
Cause #: 231-331746-02
Dear THOMAS A. WILDER :
Enclosed please find the following documents reguarding the above referenced case:
1. Notice of Administrative Writ of Withholding and;
2. Order/Notice to Withhold Income for Child Support (Administrative Writ of Withholding).
Please file these documents under the above referenced cause number.
Feel free to contact me if you have any questions regarding this matter.
Sincerely,
AMANDA J BYERLY
CHILD SUPPORT UNIT 0402E
6100 WESTERN PLACE #405
FT WORTH, TX 76107
(817) 731-9811
Enclosures
December 2000 Form 3L039
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ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT (ADMINISTRATIVE WRIT OF WITHHOLDING) Original Amended Termination State of Texas Co./City/Dist. of TARRANT COUNTY Tribunal/Case Number 231-331746-02 Employer's/Withholder's Name Child(ren)'s Name(s) DOB SSN JACKSON CONSTRUCTION CASANDRA MARIE PUGA 02/02/00 631-70-1849 Employer's/Withholder's Address 5112 SUN VALLEY FORT WORTH, TX 76119 Employer/Withholder's Federal EIN Number: RE: PUGA, JAVIER Employee's/Obligor's Name (Last, First, MI) Employee's/Obligor's Social Security Number 634-80-2224 Employee's/Obligor's Case Identifier 0009519259 PUGA, CINDY ANN Obligee Name (Last, First, MI) If checked, you are required to enroll the child(ren) indentified above in any health insurance coverage available to the employee's/obligor's through his/her employment. ORDER INFORMATION: This Order/Notice is based on the support order from TX. You are required by law to deduct these amounts from the employee's/obligor's income until further notice. $ 276.00 monthly current child support $ 90.00 monthly past-due child support - Arrears 12 weeks or greater? Yes No $ 0.00 monthly current medical support $ 0.00 monthly past-due medical support $ spousal support $ other (specify) __________________________ for a total of $ 366.00 monthly to be forwarded to the payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ 84.46per weekly pay period. $ 183.00per semimonthly pay period (twice a month). $ 168.92per biweekly pay period(every two weeks). $ 366.00per monthly pay period. REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the employee's/obligor's principal place of employment is Texas, begin withholding no later than the first pay period following the date on which this Order/Notice was delivered to the employer. Send payment on the same day of the pay date/date of withholding. The total withheld amount, including your fee, cannot exceed 50% of the employee's/obligor's aggregate disposable weekly earnings. If the employee's/obligor's principal place of employment is not Texas, for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee's/obligor's principal place of employment (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS). If remitting payment by EFT/EDI, call _____________ before first submission. Use this FIPS code: ____________________ Bank routing code: ____________________ Bank account number _______________. Make check payable to (Payee and Case Identifier): Send check to: TX CHILD SUPPORT SDU P O BOX 659791 ATTORNEY GENERAL OF TEXAS AG Case # 0009519259 Cause # 231-331746-02 SAN ANTONIO TX 78265-9791 PIN # Authorized by Print Name and Title: Deputy Attorney General for Child Support State of Texas Date: 03/23/2004 IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. OMB: 0970-0154 December 2002 Form 3N001 ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. 2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the State Child Support Enforcement Agency or party listed in number 12 below. 3. Combining Payments: You can combine withheld amounts from more than one employee's/obligor's income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 4. Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 5. Employee/Obligor with Multiple Support Withholdings. If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (See #10 below.) 6. Termination Notification: You, JACKSON CONSTRUCTION must promptly notify the Child Support Enforcement Agency or payee when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this order/notice to the Child Support Enforcement Agency or payee. EMPLOYEE'S/OBLIGOR'S NAME: JAVIER PUGA CASE IDENTIFIER: AG.No 0009519259 DATE OF SEPARATION FROM EMPLOYMENT: ____________________________________________________________ LAST KNOWN HOME ADDRESS: __________________________________________________________________________ NEW EMPLOYER/ADDRESS: ______________________________________________________________________________ 7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. Liability: If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee's/obligor's income and any other penalties set by State law. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 9. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding. 10. Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act(15 U.S.C. § 1673(b)); 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings(ADWE). ADWE is the net income left after making mandatory deductions such as: State,Federal,local taxes, Social Security taxes,statutory pension contribution, and Medicare taxes. Additional Information: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 11. Submitted by AMANDA J BYERLY Attorney General of Texas CHILD SUPPORT UNIT 0402E 6100 WESTERN PLACE #405 FT WORTH, TX 76107 12. If you or your employee/obligor have any questions, contact: AMANDA J BYERLY by telephone at (817) 731-9811 or by FAX at (817) 731-9239 or by Internet__________________________________________________________________________. IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor. OMB: 0970-0154 December 2002 Form 3N001 NCP Name: JAVIER PUGA CP Name: CINDY ANN PUGA OAG Number: 0009519259 CAUSE NUMBER 231-331746-02 IN THE INTEREST OF § IN THE 231ST DISTRICT COURT § CASANDRA MARIE PUGA § § OF § § § TARRANT COUNTY , TEXAS § NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING JAVIER PUGA , Obligor, is hereby given notice pursuant to Texas Family Code Chapter 158, Subchapter F, that his employer is immediately required to withhold the amounts specified below for payment of his current support and periodic medical support obligation, and for any overdue support arrearage, as follows: OBLIGOR: JAVIER PUGA OBLIGEE: CINDY ANN PUGA SSN: 634-80-2224 SSN: 454-57-2778 Obligor's Employer: JACKSON CONSTRUCTION 5112 SUN VALLEY FORT WORTH, TX 76119 CHILDREN Name Sex DOB SSN DL# Birthplace CASANDRA MARIE PUGA F 02/02/00 631-70-1849 N/A FT WORTH TX Current Support Due: $ 276.00 monthly Periodic Medical Support Due: $ 0.00 monthly Total Arrearage, including $ 71.54 accrued interest: $ 3,576.09 As of: 03/23/2004 Amounts to be withheld from Obligor's wages upon service of Writ: On Current Support: $ 276.00 monthly On Periodic Medical Support $ 0.00 monthly On Arrearage Owed: $ 90.00 monthly NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING Page 1 June 2001 Form 3W001 RIGHTS AND PROCEDURES Attached to this notice is a copy of the Administrative Writ of Withholding issued in this matter. JAVIER PUGA, may contest withholding on the grounds that the identity of the Obligor or the existence or amount of arrearages is incorrect by requesting a review by the Title IV-D agency, by telephone conference or in person, at the telephone number and address below: (817) 731-9811 The Office of the Attorney General CHILD SUPPORT UNIT 0402E 6100 WESTERN PLACE #405 FT WORTH, TX 76107 After a review, the Title IV-D agency may continue the attached writ in effect or may issue a new administrative writ modifying the amount to be withheld or terminating withholding. If a review fails to resolve any issue in dispute, the obligor may file a motion with the court to withdraw the administrative writ and request a hearing with the court not later than the 30th day after receiving notice of the agency's determination. Income withholding may not be interrupted pending a hearing by the court. Should a Motion to Withdraw be filed, and a hearing conducted, the court will be requested to confirm all arrearage amounts then due. If this is a reissuance of an existing withholding order on file with the court of continuing jurisdiction and the amount to be withheld for an arrearage is not being adjusted, pursuant to Texas Family Code §158.502, the preceding right and procedures regarding contests, reviews and judicial intervention into this administrative withholding process do not apply. AMANDA J BYERLY Child Support Officer Child Support Division CHILD SUPPORT UNIT 0402E 6100 WESTERN PLACE #405 FT WORTH, TX 76107 Telephone No. (817) 731-9811 Fax No. (817) 731-9239 CERTIFICATE OF NOTICE I certify a copy of this Notice of Administrative Writ of Withholding was mailed by first class to Obligor and Obligee on 03/24/04 pursuant to Texas Family Code §158.505. Cynthia Bryant Deputy Attorney General for Child Support NOTICE OF ADMINISTRATIVE WRIT OF WITHHOLDING Page 2 June 2001 Form 3W001 MC: NM 0402E Bar Code Area 115973366 FS#: 115973366 Central File Maintenance P.O. Box 12048 AUSTIN, TX 78711-2048 100 N HOUSTON ST Date: 03/24/04 Custodial Parent: CINDY PUGA FORT WORTH, TX 76196 Non-Custodial Parent: JAVIER PUGA Attorney General Case #: 0009519259 Cause #: 231-331746-02 Dear THOMAS A. WILDER : Enclosed please find the following documents reguarding the above referenced case: 1. Notice of Administrative Writ of Withholding and; 2. Order/Notice to Withhold Income for Child Support (Administrative Writ of Withholding). Please file these documents under the above referenced cause number. Feel free to contact me if you have any questions regarding this matter. Sincerely, AMANDA J BYERLY CHILD SUPPORT UNIT 0402E 6100 WESTERN PLACE #405 FT WORTH, TX 76107 (817) 731-9811 Enclosures December 2000 Form 3L039