STATE OF MAINE DISTRICT COURT Location Docket No. Judgment Creditor v. ANSWER BY EMPLOYER TO "ORDER TO WITHHOLD AND DELIVER" 14 M.R.S. § 3127-B Judgment Debtor My name is in the capacity of The following constitutes a complete listing of the amounts earned by the judgment debtor and the disposition of those amounts per pay period: 1. Judgment Debtor's Gross Pay: weekly bi-weekly monthly (1) 2. The following deductions are required by law and must be subtracted from the gross pay to calculate the judgment debtor's disposable earnings: (a) Federal Income Tax $ (b) Social Security (FICA) (c) State Income Tax (d) Medicare (e) State Employee Retirement (f) Withholding ordered by court/agency Total of lines 2(a) - (f): (2) 3. 4. 5. Judgment Debtor's Disposable Earnings (line (1) minus line (2)) Multiply amount on line (3) by .25 and enter answer here: Enter Federal minimum wage for the time period checked in line 1 (As of 7/24/09: Weekly = $290.00; Bi-weekly = $580.00; Monthly = $1257.00) Subtract line (5) from line (3) and enter answer here: (3) (4) . I am employed by . (5) (6) 6. 7. Court ordered payments (from paragraph #1 of Order to Withhold, but based on the time period checked in line 1 above. If paragraph 1 is blank, put N/A on this line): (7) Enter the least of the amounts of lines (4), (6) or (7): (8) 8. The amount in line (8) is the maximum amount that may be withheld. From this amount, the employer is allowed to retain $1.00 for each check issued and forwarded to the Judgment Creditor. Pursuant to the Order to Employer to Withhold and Deliver and the calculations in this form of the disposable earnings and the maximum amount subject to withholding, the amount see forth in line (8) is being withheld from the wages of the judgment debtor for the time period specified in line (1) above. I swear/affirm that the above information regarding earnings and deductions of the judgment debtor is true and complete. Date: Signature Personally appeared the above-named and made oath that the foregoing Answer is true. Date: Notary Public / Attorney / Clerk MJ-007, Rev. 06/14 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com