AFFIDAVIT FOR WAGE DEDUCTION ORDER 2316 (Rev. 5/16) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT PLAINTIFF vs CASE NUMBER DEFENDANT 21 to 40 days after date of issuance of Summons RETURN DATE EMPLOYER on oath states: 1. I believe employer __________________________________________________ is indebted to the Judgment Debtor, ____________________________________________________ for wages due or to become due. Employer's address: 2. The last known address of the Judgment Debtor is: I request that a summons be issued to the employer. Furthermore, I certify that a copy of the wage deduction notice was mailed to the Judgment Debtor by First Class Mail, at the judgment debtor's last known address prior to the filing of this wage deduction proceeding. Name: DuPage Attorney Number: Attorney for: Pro Se AFFIDAVIT FOR WAGE DEDUCTION ORDER File Stamp Here Affiant: Sworn and Subscribed before me Date: Notary Public Address: City/State/Zip: Telephone Number: Email: I, the undersigned, certify under penalties as provided by law pursuant to 735 ILCS 5/1-109 that the statements set forth in this instrument are true and correct. 1. Judgment in the above captioned case was entered on ___________________ 2. The amount of Judgment .............................................................................. 3. Allowable costs previously expended: a) Initial filing fee ................................................................................ b) Original and alias summons ............................................................ c) Filing and summons costs of prior supplementary proceedings ..... 4. Filing and summons costs for this proceeding ............................................. 5. Interest due on Judgment to date .................................................................. $ $ $ $ $ $ CERTIFICATE OF ATTORNEY OR JUDGMENT CREDITOR TOTAL $ DEDUCT: Total amount paid by or on behalf of the Judgment Debtor prior to this proceeding ............................................... $ BALANCE DUE JUDGMENT CREDITOR NOTE: $ Judgment Creditor / Attorney Answer to interrogatories on reverse side are to be filed on or before the return date CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © American LegalNet, Inc. WHEATON, ILLINOIS 60187-0707 FOUR (4) COPIES OF THIS AFFIDAVIT MUST BE SERVED ON THE EMPLOYER www.FormsWorkFlow.com AFFIDAVIT FOR WAGE DEDUCTION ORDER 2316 (Rev. 5/16) Case Number: Return Date: 1. Were any wages, salary or commissions due the Judgment Debtor, when you were served the Wage Yes No Deduction Summons? 2. State any facts affecting the wage deductions: Prior garnishment, etc.: Date of last employment: 3. Your answer under oath is to be e-filed, at www.i2file.net, with the Clerk of the Circuit Court on or before the return date on the summons. Your failure to answer will cause judgment for amount due to date be entered against the employer. (735 ILCS 5/12-807) 4. Judgment Debtor is paid: Weekly Biweekly Semi-monthly Monthly Other: (A) (B) WAGE DEDUCTION INTEROGATORIES / ANSWERS CALCULATION TO DETERMINE AMOUNT OF WITHHOLDING (A) Gross Wages minus mandatory contributions to pension or retirement plan: $ (B) METHOD I - 15% of Line (A): ..................................................................... $ hourly wage prescribed by Section 4 of the Minimum Wage Law (C) METHOD II - the greater of (a) the amount that the weekly disposable earnings exceeds the minimum hourly wage or (b) the minimum (1) Enter Total FICA, State and Federal Tax and Medicare: $ (2) Subtract Line (1) from Line (A): $ $ (C) (D) (E) (F) (G) (H) (3) Enter Minimum Wage per pay period: $ (4) Subtract Line(3) from Line (2): (enclose negative amount in parenthesis) (D) Enter the lesser of Line (B) or Line (C): ......................................................... $ (E) Enter Child Support or other Court Ordered Deduction: ................................ $ (F)* Subtract Line (E) from Line (D): (enclose negative amount in parenthesis) $ (G) Subtract Employer's Statutory Fee (735 ILCS 5/12-814): ..............................$ (whichever is greater; $12.00 or 2% of the amount to be deducted) (H) Amount to be applied to judgment: ................................................................ $ * Line (F) is the amount to be withheld from the employee's paycheck each pay period after the date of service of Summons and not to be disbursed until further order of Court. 1. Fill out and sign the certificate below. 2. A copy of this should be sent to the Attorney for the Plaintiff or Judgment Creditor, Defendant, and e-filed with the Circuit Court Clerk at www.i2file.net . 3. You will receive a copy of a Court Order instructing you how to proceed and where to send any withheld funds. DO NOT SEND MONIES WITHHELD TO THE CIRCUIT COURT CLERK Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), the under-signed 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 / Answer to the Defendant. INSTRUCTIONS THIRD PARTY EMPLOYER CERTIFICATION Print full name Phone Number Signature of Employer / Agent CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 Date American LegalNet, Inc. www.FormsWorkFlow.com