STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT CLINTON COUNTY, CARLYLE, ILLINOIS ) Plaintiff ) vs. ) Case No. ) ) Return Date: Defendant ) and ) ) 21 to 40 days after date of issuance of summons ) Employer ) Affidavit for Wage Deduction Order on oath states: 1. I believe employer is indebted to the judgment debtor for wages due or to become due. 2. The last known address of the judgment debtor is: I requested that a summons issue directed to employer and I certify that a copy of the attached Wage Deduction Notice was mailed to judgment debtor, by first class mail, at his/her last known address prior to filing of this wage deduction proceeding. Name: Affiant: Attorney for Judgment Creditor: Under penalty of perjury as provided by law pursuant to 735 ILCS 5/1-109 the affiant certifies Address: that the statements set forth herein are true and City, State, Zip: correct. Telephone: Certificate of Attorney or Judgment Creditor NOTE: Non-attorneys must also submit a copy of the underlying judgment or a certification by the clerk of the court that entered the judgment. I, the undersigned certify under penalties as provided by law pursuant to 735 ILCS 5/1-109 that the following information is true: 1. Judgment in the above captioned case was entered on . 2. The amount of judgment was $ 3. Allowable costs previously expended: a. Initial filing fee $ b. Original and alias summons $ c. Filing and summons costs of prior supplementary proceeding $ 4. Filing and summons cost for this proceeding $ 5. Statutory interest due on Judgment from date above $ Total $ DEDUCT: Total amount paid by or on behalf of the judgment debtor prior to this proceeding $ BALANCE DUE JUDGMENT CREDITOR $ Attorney or Judgment Creditor American LegalNet, Inc. www.FormsWorkFlow.com Return Date: Case No. Interrogatories/Answer to Wage Deduction Proceedings Employer/Agent: , certifies under penalty of perjury that the following Answer is true and correct to the best of her/his knowledge and belief concerning the property of the judgment debtor: Debtor Name: SS# Do you pay monies to the judgment debtor listed above? Yes No State whether any funds paid to the debtor are for disability, retirement or are in any other way exempt or subject to other Court Order: One Pay Period equals: day(s) week(s) month(s) Calculation to Determine Amount of Withholding: (A) Gross Wages minus mandatory contributions to pension or retirement plan is (A) (B) Method I 15% of (A) = (B) Method II (C) Enter Total FICA, State and Federal Tax and Medicare (C) (D) Subtract (C) from (A) = (D) (E) Enter minimum wage per pay period (for each pay period, 45 times (E) the federal minimum hourly wage or, under a wage deduction summons served on or after January 1, 2006, the minimum hourly wage prescribed by Section 4 of the Illinois Minimum Wage Law, whichever is greater) (F) Subtract (E) from (D) (F) (G) Enter the lesser of line (B) or (F) (G) (H) Enter Child Support of other Court Ordered Deduction (H) (I) Subtract (H) from (G) (I) (J) -814): greater of 2% of amount (J) required to be deducted or $12.00 (K) Amount to be applied to judgment (K) service of Summons and not disbursed until further order of Court. INSTRUCTIONS 1. Mail a copy of this Answer to the Court and mail to attorney for Plaintiff and give a copy to the Defendant. 2. You will receive a copy of a Court Order by fax or mail instructing you how to proceed and where to send deducted funds. THIRD PARTY EMPLOYER CERTIFICATION Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), the undersigned certifies that the statements set forth in this instrument are true and correct and that I have either mailed or hand delivered a copy of this completed Interrogatories/Answers to the Defendant. Date: Signature of Employer/Agent: Print full name: Employer Name: Employer Address: Employer Phone Number: Fax Number: American LegalNet, Inc. www.FormsWorkFlow.com