At the end of the form when finished. FAX NO.: ATTORNEY FOR STATE TAX AGENCY: NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE BRANCH NAME: APPLICATION OF (Name): TAXPAYER / RESPONDENT EARNINGS WITHHOLDING ORDER FOR TAXES NAME OF STATE TAX AGENCY: CASE NUMBER: TAX AGENCY NUMBER: 1. The State's Application for Earnings Withholding Order for Taxes came on for hearing on (date): in Dept.: Div.: Room: before (name of judicial officer): 2. a. Attorney for state tax agency.
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