IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT MARION COUNTY, ILLINOIS _______________________________________ Plaintiff vs _______________________________________ Defendant and _______________________________________ Employer CASE NO: ________________________________ RETURN DATE: ___________________________ (21 to 40 days after date of issuance of summons) 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. Employer's address is: _____________________________________________________________________________________________. 2. The last known address of the judgment debtor is: _________________________________________________________ _________________________________________________________________________________________________. I request that the Circuit Clerk issue a summons to the employer and I certify that a copy of the Wage Deduction Notice was mailed to the judgment debtor, by first-class mail, at his/her last known address prior to the filing of this wage deduction proceeding. Attorney or Party, if not represented by Attorney Name _____________________________________ ARDC # ___________________________________ Firm Name _________________________________ Attorney for ________________________________ Address ____________________________________ City & Zip Code _____________________________ Telephone __________________________________ Affiant: ____________________________________________ Under penalty of perjury as provided by the law pursuant to 735 ILCS 5/1-109 the . affiant certifies that the statements set forth herein are true and correct Date: __________________________________, 20 _________ 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 ____________________, 20 _____. 2. The amount of the Judgment was $ _______________________________________ 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. 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) $ _______________________________________ $ _______________________________________ (OVER) *NOTE: Four (4) copies of this Affidavit must be served on the employer. Answer to interrogatories on the reverse side hereof to be filed prior to the above stated Return Date. (SEE REVERSE SIDE) American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT MARION COUNTY, ILLINOIS INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS Returned Date: _______________________________ Case No. ____________________________________ 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: _____________________________________________ Social Security Number: _____________________________ YES NO Do you pay monies to the judgment debtor listed above? 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: (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) $________________________________ (E) Enter minimum wage per5 pay period (for each week in pay period, 45 times the federal minimum hourly wage or, under a wage deduction summons served on or after January 1, 2006, the minimum 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 of other Court Ordered Deduction (I) Subtract (H) from (G) (I) $________________________________ (J) Subtract Employer's Statutory Fee (5/12-814): greater of 2% required to deducted or $12.00 (K) Amount to be applied to judgment (J) $________________________________ (K)$________________________________ (F) $________________________________ (G) $________________________________ (H) $________________________________ *Line (F) is the amount to be withheld from employee's paycheck each pay period after the date of service of Summons and not to be disbursed until further order of Court Signature of Employer ________________________________________ INSTRUCTIONS 1. 2. Mail a copy of this Answer to the Court and mail to attorney for Plaintiff and give a copy to the Defendant. You will receive a copy of a Court Order by fax or mail instructing you how to proceed and where to send deducted funds. Agent: ______________________________________ Employer Name: _______________________________ Address: _____________________________________ City/ State/ Zip Code: ___________________________ Phone: _______________________________________ Fax: _________________________________________ Ronda Yates Clerk of the Circuit Court Marion County Courthouse 100 Ea