Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinois � cookcountyclerkofcourt.orgPage 1 of 4 � Plaintiff(s),v. Defendant(s),XXX-XX- � Respondent.Case No. � � (21 to 40 days after date of issuance of summons) I, the undersigned, certify under penalties as provided by law under 735 ILCS 5/1-109, that the following information is true.1. I believe Respondent � is indebted to the JudgmentDebtor � for wages due or to become due.2. The last kno .3. I request that a summons issue directed to Respondent. � 1. Judgment in this case was entered on� .2. Amount of Judgment $ � � 3. Allowable costs previously expended:a. � � b. Original and alias summons $ � � c. Filing and summons costs of prior supplementary proceedings $ � � 4. Filing and summons cost for this garnishment $ � �5. Interest at 9% pursuant to statute $ � �������������� 6. Total $ � 7. � Total amount paid by or on behalf of the Judgment Debtor before� $ � � 8. Balance due Judgment Creditor $ � � Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinois � cookcountyclerkofcourt.orgPage 2 of 4 � Employer/Agent: � Court Date: � Defendant222s Name: � � SSN. xxx-xx- � � Case No. � Defendant222s Address � � Attorney or Judgment Creditor Signature Print Name Atty. No.: � Atty Name: � � Atty. for: � � Address: � � City: � � State: � Zip: � Telephone: � Primary Email: � � Do you pay any money to the Defendant listed above? � � Yes � No � If terminated, date: � .Of the funds paid to the debtor, are any of those funds: Subject to prior court ordered deduction (including child/spouse support) Case Number,State, County � . Disability? � � Retirement? � � Otherwise exempt? (Describe � )CREDITORUnder penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS Defendant at the address shown above on � .Signature: � � Name: � Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinois � cookcountyclerkofcourt.orgPage 3 of 4 � 1. 2. 3. www.cookcountyclerkofcourt.org and proceed with the eFile process.Do you pay debtor: � Every week � Every 2 weeks � � Semi-monthly � Monthly � � Other � A. Gross wages per paycheck minus mandatory contributions to pensions or retirement plan � $ � � B. 15% of (A) = $ � � C. Enter total FICA, State Tax, Federal Tax and Medicare $ � � D. Subtract (C) from (A) = $ � � E. If debtor is paid every week, enter $371.25If debtor is paid every two weeks, enter $742.50If debtor is paid semi-monthly, enter $804.37If debtor is paid monthly, enter $1,608.75If other, multiply 45 times state minimum wage (currently $8.25)times number of weeks in pay period � $ � � F. Subtract (E) from (D) (Enclose a negative number in parentheses, e.g., ($50.00)) $ � � G. Enter the Lesser of Line (B) or (F) $ � � H. Enter Child Support or other Court Ordered Deduction $ � � I. Subtract (H) from (G) (Enclose a negative number in parentheses, e.g., ($50.00)) $ � � J. Subtract Employer222s Statutory Fee (2% of line 223I224). See 735 ILCS 5/12-814. $ � � K. Amount to be applied to Judgment $ � � Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinois � cookcountyclerkofcourt.orgPage 4 of 4 � Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 correct and that I have either mailed or hand delivered a copy of this completed Interrogatories/Answer to the Clerk, Plaintiff222s attorney and Defendant. Date: � Employer/Agent Signature: � Employer/Agent: � Address: � City: � � State: � Zip: � Telephone: � Primary Email: �