(Year) IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) Plaintiff(s) ) ) vs. ) ) Defendant(s) ) Gen No . ) ) Return Date: and ) 21 to 40 days after the 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 request that a summons issue , directed to the 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 the filing of this wage deduction proceeding. Prepared by: Name: Pro Se Address: City: State: Phone: Zip Code: ARDC #: Fax: E - Affiant: Under penalty of perjury as provided by law pursuant to 735 ILCS 5/1 - 109 the affiant certifies that the statements set forth herein are true and correct . 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 the day of , 2. The amount of Judgment was: ................................ ............................... $ 3. Allowable costs previously expended: a. Initial filing fee ................................ ................................ ..................... $ b. Original and alias summons ................................ ............................... $ c. Filing and summons c ost 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 proceedings $ BALANCE DUE JUDGMENT CREDITOR $ Attorney or Judgment Creditor American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) Plaintiff(s) ) ) vs. ) ) Defendant(s) ) Gen No . ) ) Return Date: and ) Employer ) INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS Employer/Agent: certifies 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: Last Four Digits of Soc. Security No. Do you pay monies to the judgment debtor listed ab ove? Yes No State whether any funds paid to the debtor are for disability, retirement or are in any other way exempt or not subject to a wage deduction Order : One Pay Period equals: day(s) or week(s) or month(s) CALCULATION TO DETERMINE AMOUNT OF WITHHOLDING: A. Gross Wages minus mandatory contributions to pensions 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 week (45 x federal minimum or IL minimum, whichever is greater) ....... E. F. Subtract E from D ................................ ................................ ................................ ....................... F. G. Enter the lesser of Line B or F ................................ ................................ ................................ ... G. H. Enter Child Support or other Court Ordered Deduction ................................ ............................. H. I. Subtract H from G ................................ ................................ ................................ ...................... I. J. ( 735 ILCS 5/12 - 814) 2% of amount required to be deducted (This sum is charged to Judgment Debtor) ................................ ......... J. K. Amount to be applied to judgment ................................ ................................ ............................. K. disbursed until further order of Court. I, the undersigned certify under penalties as provided by law pursuant to section 1 - 109 of the Code of Civil Procedure of the Illinois Compiled Statutes that the statement s set forth in this instrument are true and correct. Signature of Employe r NOTE: See Mailing Instructions on Reverse Side American LegalNet, Inc. www.FormsWorkFlow.com 171 - 7b (Rev 1 2 / 1 7 ) American LegalNet, Inc. www.FormsWorkFlow.com