IN THE JUVENILE COURT OF COUNTY, ALABAMA In the Matter of , a Child This Withholding Order is entered pursuant to the provisions of Ala. Code 1975, Section 15-18-143, and/or Rule 26.11, Alabama Rules of Criminal Procedure, as a means of collecting monies paid pursuant to a juvenile delinquency proceeding. It is therefore ORDERED by the Court as follows: 1. The above-named party was ORDERED on to pay the sum of $ for court-ordered monies. 2. The above-named party222s present employer or any successive employer is hereby ORDERED to withhold from employment income due or to become due $ per month until paid in full. The Employer shall remit the total amount deducted on a MONTHLY basis to: . 3. When the restitution payments are ordered paid directly to the Clerk of this Court, there shall be paid an additional $1.00 administrative fee provided in Ala. Code 1975, Section 12-19-26, with each periodic payment of restitution. 4. This Order shall become binding after service upon the Employer and shall remain in effect until the sum of $ has been remitted to the Clerk of the Court to satisfy the court-ordered employment withholding obligation unless the Order has been sooner modified or terminated by the Court. When the total amount ordered by the Court has been remitted to the Clerk of the Court, the Employer is released from his obligation to remit further payments. This Order is effective as to any current or future employer of the above-named party. 5. The Employer222s copy of this Order shall be: a. Served immediately upon the Employer; OR b. Remain in the court file until employment is found as required by this Court; OR c. Remain in the court file until a determination is made by the Court that the Court222s Order was not complied with. d. When order is served, service shall be by personal service; certified mail. 6. The Employer shall not discharge the above-named party solely because of the Order or any other process issued as a result thereof. Any employer who violates this Order may be deemed in contempt of court and may be compelled by the Court to reinstate such employee. 7. The above-named party and the employer shall promptly notify this Court of the Clerk of the Court if payments are discontinued as a result of any layoff, suspension, discharge, or resignation or of any change in employment including the name and address, if known, of any new or successive employer. 8. Any person who willfully refuses to comply with any court order issued pursuant to Ala. Code 1975, Section, 15-18-143, directing such person to withhold, deliver or pay over any employment income may be deemed in contempt of court and may be held liable to the victim for any restitution lost. 9. Any person who complies with the Order for Withholding restitution issued pursuant to Ala. Code 1975, Section 15-18-140 et seq., shall not be held liable to the above-named party or other person claiming any rights derived for wrongful withholding or wrongful conversion of any assets or income. 10. You are hereby ordered to return the enclosed Answer to Order of Withholding for Fines, Assessment, and Restitution within 14 days of service of this Order to: . 11. Other: . State of Alabama Unified Judicial System Form JU-42 Rev. 10/11 Case Number WITHHOLDING ORDER 226 COSTS, FINES, ASSESSMENTS AND RESTITUTION Employer Information: Employer / Company Name Address of Employer City, State, Zip Code Employer Telephone Party Information: Party Name Party Social Security Number Done this the day of , . Judge American LegalNet, Inc. www.FormsWorkFlow.com