TX Response Form

IMPORTANT NOTE: Complete This Form Online
Go to https://www.childsupportliens.com/csln3/tx_response_form
Additional Completion Options:
SAVE as a PDF and ATTACH and EMAIL to TexasCSLN@childsupportliens.com
or
Please PRINT and FAX to 888-282-0471

Child Support Division
Special Collections Unit

Response to Insurance Claim Notice

CLAIMANT:

SSN:

CLAIM #:

IV-D Case #:

Match ID #:

Response to Notice

Withholding has been placed on the periodic benefits the claimant will receive

A Lien has been placed on any possible settlement the claimant will receive

The Withholding and/or Lien can not be placed for the following reason(s):

Claim DENIED

Medical only

Claim previously settled on (date):

Other:

Attorney Information (if known)

Claimant is not represented by Counsel

Claimant is represented by Counsel:

Attorney name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Employer Information (if known)

Claimant is currently employed

FEIN:

Contact Name:

Employer name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Completed by:

Adjuster Attorney

Name:

Phone:

Email:

Fax: