VTB Form Y - 8 0 4 /2018 See Vt. LBR 1007 - 1(l)(1)(A) & 3015 - 6(c)(1) UNITED STATES BANKRUPTCY COURT DISTRICT OF VERMONT In re: . Chapter 13 Debtor (s) . Case # W AGE W ITHHOLDING A UTHORIZATION / C ONSENT TO A UTOMATIC D EBITS FROM B ANK A CCOUNT Part A: Wage Withholding Authorization - Debtor n ame: Income from e mployment ? Yes No If no, proceed to Part B Automatic Debits from Bank Account If yes, complete the following : A mount employer is to deduct per pay period : $ mployer : t elephone #: a ddress: I for the purpose of making c hapter 13 plan payments during the term of the confirmed plan in this case. I authorize the chapter 13 t rustee, Jan M. Sensenich, to contact the employer(s) who is/are withholding wages to modify the amount of the withholding to comport with any Court - approved modification or amendment of the plan , without our further and separate author ization or Order, provided the c hapter 13 t rustee gives notice to our attorney at the same time as he communicates th at request for modification of the withholding amount to the employer(s). Date: Wage Withholding Authorization Joint Debtor n ame Income from e mployment? Yes No If no, proceed to Part B Automatic Debits from Bank Account American LegalNet, Inc. www.FormsWorkFlow.com If yes, complete the following : Amount employer is to deduct per pay period: $ mployer : a ddress: for the purpose of making chapter 13 plan payments during the term of the confirmed plan in this case. I authorize the chapter 13 trustee, Jan M. Sensenich, to contact the employer(s) who is/are withholding wages to modify the amount of the withholding to comport with any Court - approved modification or amendment of the plan , without our further and separate author ization or Order, provided the chapter 13 trustee gives notice to our attorney at the same time as he communicates that request for modification of the withholding amount to the employer(s). Joint Date: Part B Automatic Debits from Bank Account I am /we are not able to authorize direct wage withholding because I/we do not have income from an employer. I /we hereby agree to make plan payme nts in the amount of $ per month , $ per week, or $bi - weekly, by automat ic debit from a bank account using ACH transfer or similar means , and understand the Court will enter an order directing that plan payments be made by automat ic debit from a bank account . I/w e will contact the c hapter 13 t rustee for the pertinent bank routing information within one week of the date of this form. Date: Date: THE DEBTOR(S) MUST F ILE THIS FORM WITH T HEIR CHAPTER 13 PLAN See Vt. LBR 1007 - 1(l); see also Vt. LBR 3015 - 6(c) American LegalNet, Inc. www.FormsWorkFlow.com