CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County Case No: Petitioner vs. Respondent's Soc. Sec. No: Respondent INTERROGATORIES TO EMPLOYER - WAGE DEDUCTION Employer/Agent: certifies under penalty of perjury that the following answers are true and correct to the best of her/his knowledge and belief concerning the property of the Respondent: DO YOU PAY MONIES TO THE RESPONDENT LISTED ABOVE: [YES] [NO] If Respondent is no longer employed by you, please give termination date: STATE WHETHER ANY FUNDS paid to Respondent are for disability, retirement or are in any other way exempt or subject to another court order (Examples: Child support, lien by Federal Government): ONE PAY PERIOD EQUALS: day(s) week(s) bi-monthly month other WITHHOLDING You are required by law to withhold the lesser of (1) 15% per week of the gross amount paid the employee named herein for any work week; or (2) the amount by which disposable earnings of said employee for a week exceed forty-five times the minimum hourly wage in effect at the time the amounts are payable (Example: from July 1, 2009 the minimum wage will be $8.00 per hour; 45 x 8.00 = $360.00). On a Wage Deduction Order, the employer is entitled to a $12 once per proceeding (not per payroll) fee or 2% of the sums withheld. NOTICE TO EMPLOYER - You must complete and return these Interrogatories. The original is sent back to the Circuit Clerk; you must mail a copy to the Petitioner or his/her attorney; you should give a copy to the Respondent; and you should keep a copy for yourself. YOU MUST FILE YOUR ANSWER EVEN IF THE RESPONDENT IS NO LONGER EMPLOYED BY YOU. THE ANSWER MUST BE FILED ON OR BEFORE THE DATE ON THE SUMMONS. UPON RECEIPT OF THE WITHHOLDING ORDER, ANY MONEY WITHHELD IS SENT TO THE PETITIONER'S ATTORNEY OR, IF NONE, THE PETITIONER DIRECTLY. (DO NOT SEND ANY OF THE WITHHELD MONEY TO THE CLERK OF THE CIRCUIT COURT. HOW TO CALCULATE THE AMOUNT OF WAGES TO WITHHOLD: A B C D Gross Wages, minus mandatory contributions to pensions or retirement plan $ A Enter total of FICA, Medicare, Federal Tax, and State Tax B $ Subtract Line B from Line A (This is net pay) C $ Enter If paid every week $ 360.00 $ D amount of If paid every 2 weeks $ 720.00 Exempt Wages If paid twice a month $ 780.01 If paid every month $1,560.00 E Subtract Line D from Line C E $ F 15% of Line A F $ G Enter the LESSER of Line E or Line F G $ H Enter amount of Child Support or other Court ordered deduction H $ I Subtract Line H from Line G I $ J Employer's Statutory Fee: Greater of $12.00 or 2% of Line I J $ K Subtract Line J from Line I: Amount to be applied to Judgment $ K Line I is the amount to be withheld from the employee's paycheck as of the date the Summons is served on you. This calculation should be done for each pay period. Do not disburse that amount until further order of the Court. AFFIDAVIT Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the answers to the Interrogatories are true and that he/she has mailed first class or hand-delivered a copy of this answer to the Respondent at his/her last known address. Employer/Agent: Print name Signature Date: Address: City/State/Zip: , 20 Linda S. Frank Revised: 01/09 Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 White-Circuit Clerk Canary-Employer Pink-Petitioner American LegalNet, Inc. www.FormsWorkflow.com Goldenrod-Respondent