Affidavit for Wage Deduction Order NOTE: FOUR (4) COPIES OF THIS AFFIDAVIT MUST BE SERVED ON THE EMPLOYER STATE OF ILLINOIS COUNTY OF MADISON IN THE CIRCUIT COURT OF THE THIRD JUDICIAL CIRCUIT CLERK ) ) ) ) ) ) ) ) ) ) Plaintiff-Judgment Creditor vs. Defendant-Judgment Debtor No. Answer Date (File Stamp Above) (21 to 40 days after date of issuance of summons) AFFIDAVIT FOR WAGE DEDUCTION ORDER on oath states: is indebted to the judgment for wages due or to become due. 1. I believe employer debtor 2. The last known address of the judgment debtor is . I request that the Circuit Court Clerk issue summons to the employer. I certify that a copy of the wage deduction notice was mailed to the judgment debtor at the last known address prior to the filing of this wage deduction affidavit. Name Attorney No. Address City Phone Date Notary Public CERTIFICATE OF ATTORNEY OR JUDGMENT CREDITOR I, the undersigned certify under penalties as provided by law pursuant to section 1-109 of the Code of Civil Procedure 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 the judgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 3. Allowable costs previously expended: a) Initial filing fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b) Original and alias summons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c) Filing and summons cost of prior supplementary proceedings . . . . . $ 4. Filing and summons cost for this garnishment . . . . . . . . . . . . . . . . . . . . . . . . $ 5. Interest due on judgment to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ TOTAL $ Deduct: Total amount paid by or on behalf of the judgment debtor prior to this garnishment . . . . . . . . . . . . . . . . . . . . . . . . . . $ BALANCE DUE JUDGMENT CREDITOR $ Judgment Creditor/Attorney American LegalNet, Inc. www.FormsWorkFlow.com INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS Return Date:_______________ Case No. _______________________ Employer/Agent: , certifies under penalty of perjury that the following Answer is true and correct to the best of his/her knowledge and belief concerning the property of the judgment debtor. Debtor Name: Do you pay monies to the judgment debtor listed above? Social Security No Yes xxx-xxNo 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 (B) METHOD I ­ 15% OF (A) = METHOD II (C) Enter Total FICA, State and Federal Tax and Medicare (D) Subtract (C) from (A) = (A) (B) (C) (D) (E) Enter Minimum wage per pay period (for each week in 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) (G) Enter the lesser of Line (B) or (F) (H) Enter Child Support or other Court Ordered Deduction (I) Subtract (H) from (G) (J) Subtract Employer's Statutory Fee (§5/12 ­ 814) (K) Amount to be applied to judgment (F) (G) (H) (I) (J) (K) Line I is the amount to be withheld from employee's pay check as of the date of service of Summons and not disbursed until further order of the Court. Signature of Employer 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 instruction you how to proceed and where to send deducted funds. DO NOT SEND THE MONIES WITHHELD TO THE CIRCUIT CLERK. Employer/Agent: Agent Name Employer Name Address Clerk of the Circuit Court Madison County Courthouse 155 N. Main St. Ste. 120 Edwardsville, IL 62025 Phone Fax NOTE: A copy of this Answer should be mailed to the Court, Attorney for Plaintiff or Judgment Creditor and to the Defendant. American LegalNet, Inc. www.FormsWorkFlow.com