IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT STEPHENSON COUNTY, ILLINOIS DEFENDANT(S), } } } } } } } EMPLOYER. } } } } PLAINTIFF(S), VS. and 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 a summons issue directed to 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 filing of this wage deduction proceeding. Name: Attorney for Judgment Creditor: Address: City/ZIP: Telephone: 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 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 American LegalNet, Inc. www.USCourtForms.com IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT STEPHENSON COUNTY, ILLINOIS Return Date __________________________________ Case Number:______________________________ INTERROGATORIES/ANSWER TO WAGE DEDUCTION PROCEEDINGS Employer/Agent ______________________________________ certifies under penalty of perjury that the following Answer is true and corrects to the best of her/his knowledge and belief concerning the property of the judgment debtor: Debtor Name: ________________________________________ Soc. Sec. No____________________________________ Do you pay monies to the judgment debtor listed above? Yes _____________________ No _____________ 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 plans 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 pay period (45 x $8.00 per week) (E) ________________________ (F) Subtract (E) from (D) (F) ________________________ (G) Enter the lesser of Line (b) or (f) (G) ________________________ (H) Enter Child Support of other Court Ordered Deduction (H) ________________________ (I) Subtract (H) from (G) (I) ________________________ (J) Subtract Employer’s Statutory Fee (5/12-814) (J) ________________________ (K) Amount to be applied to judgment (K) ________________________ Line I is the amount to be withheld from 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 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 instructing you how to proceed and where to send deducted funds. Employer/Agent: Agent Name Clerk of the Circuit Court Employer Name County Courthouse Address Street Phone City, State, Zip 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.USCourtForms.com