STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 22nd JUDICIAL CIRCUIT McHENRY COUNTY ________________________________________Plaintiff Case Number___________________________________________ Vs. ________________________________________Defendant Return Date________________________________________ *21 to 40 days after date of issuance of summons and ________________________________________Employer AFFIDAVIT FOR WAGE DEDUCTION ORDER _______________________________________________________________________________ on oath states: 1. 2. I believe employer ________________________________________________________________ is indebted to the Judgment Debtor ______________________________________________________________________________ for wages due or to become due. Employer’s address is ______________________________________________________ ________________________________________________________________________________________________ The last known address of the Judgment Debtor is ________________________________________________________ _________________________________________________________________________________________________ I request that a summons issue directed to employer and I certify that a copy of the attached Wage Deduction Notice was mailed to the Judgment Debtor, by first class mail, at his/her last known address prior to filing of this wage deduction proceeding. 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. Name ________________________________________________________ Attorney for ___________________________________________________ Address ______________________________________________________ City, State, Zip _________________________________________________ Telephone _____________________________________________________ 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 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 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 cost for this proceeding .........................................................$___________________________________ 5. Statutory interest due on Judgment from date above..............................................$___________________________________ TOTAL ...................................................................................................................$___________________________________ DEDUCT: Total amount paid by or on behalf of the Judgment Debtor prior to this proceeding.....................................................................................$___________________________________ BALANCE DUE JUDGMENT CREDITOR....................................................$___________________________________ _____________________________________________________ Attorney or Judgment Creditor CV-AFF3 (revised 12-01-2006) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 22nd JUDICIAL CIRCUIT McHENRY COUNTY ________________________________________Plaintiff Case Number___________________________________________ Vs. ________________________________________Defendant and ________________________________________Employer Return Date________________________________________ *21 to 40 days after date of issuance of summons INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS 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:________________________________________________________ Social Security Number:____________________ Do you pay monies to the Judgment Debtor listed above? Yes ___________________ No____________________ State whether any funds paid to the Judgment 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) (B) (F) (G) (H) (I) (J) (K) Gross Wages minus mandatory contributions to pension or retirement plans is ....(A) ________________________________ 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 pay period (45 x Federal minimum wage) or (45 x Illinois minimum wage), whichever is greater ...................................(E)_________________________________ Subtract (E) from (D) .............................................................................................(F) ________________________________ Enter the lesser of Line (B) or (F) ..........................................................................(G) ________________________________ Enter Child Support or other Court Ordered Deductions .......................................(H) ________________________________ Subtract (H) from (G) .............................................................................................(I) _________________________________ Subtract Employer’s Statutory Fee (5/12-814) .......................................................(J) _________________________________ Amount to be applied to Judgment .........................................................................(K) ________________________________ Line (I) is the amount to be withheld from the employee’s paycheck as of the date of service of Summons and not disbursed until further order of Court. Signature of Employer ________________________________________________ INSTRUCTIONS 1. Mail the original of this Answer to the Court, mail a copy to the Attorney for Plaintiff and give a copy to the Defendant. 2. You will receive a copy of a Court Order by fax or mail instructing you how to proceed and where to send deducted funds. Employer/Agent Agent Name____________________________________________ Clerk of the Circuit Court Employer Name_________________________________________ McHenry County Government Center Address________________________________________________ 2200 N. Seminary Avenue City, State Zip___________________________________________ Woodstock, Illinois 60098 Telephone______________________________________________ Fax___________________________________________________ Note: The original of this Answer should be mailed to the Court, a copy mailed to the Attorney for Plaintiff or Judgment Creditor and to the Defendant. CV-AFF3 (revised 12-01-2006) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com