CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at Case No. Court Address STATE OF MARYLAND City/County vs. Defendant's Name Date of Birth Address City, State, Zip TRACKING NUMBER Home Telephone (Additional tracking numbers may be placed at the top of this page.) Work Telephone XXX - XX Social Security Number EARNINGS WITHHOLDING ORDER (RESTITUTION) To the Employer: Name Address City, State, Zip Phone Number A judgment of restitution was entered on against Criminal Procedure Article, § 11-617 and subject to the withholding limits imposed by federal and state law (as shown on reverse side), you are required to deduct from the Restitution Obligor's income the amount of: 20% of the Restitution Obligor's earnings after other deductions required by law; or (For a delinquent account) % of the Restitution Obligor's earnings after other deductions required by law. Subject to the withholding limits, you also have the option to deduct a fee to offset your withholding costs. That amount is $2 per pay period. You must begin withholding at the beginning of the next pay period on a regular and continuing basis. Send payment within 10 days after the date of the withholding (i.e., the date the income was withheld from Restitution Obligor's pay), to the Baltimore, MD 21203 or Maryland Division of Parole and Probation (P&P), at P.O. Box 2356, Maryland Department of Juvenile Services (DJS), at 120 W. Fayette Street, Baltimore, MD 21201. With each payment include the case number and the date of withholding. If you have a question, Call P&P or DJS at: . Telephone No. Date Judge Important information for Employer and Restitution Obligor on the reverse side (or page 2) of this form. CC-DC/CR 84 (Rev. 4/2008) (front) American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL INFORMATION TO EMPLOYERS 1. Inability to comply: if you cannot comply with this Order, you must notify this Court and P&P or DJS immediately of your reason(s). 2. Liability: If you fail to give notice of your inability to comply with this Order or fail to withhold income, to make payments, or to provide information as this Order directs, you are liable for damages and subject to a fine. 3. Anti-Discrimination: You are subject to a fine determined under State law for discharging from employment, refusing to employ or to promote, or taking other adverse action against an employee because of the withholding. 4. Binding Effect: This Order is binding on you until further notice by the State Central Collection Unit, P&P or DJS, or a court. 5. Priority: Withholding under this Order has priority over any other legal process under state law against the same income, except for support payments. Federal tax levies in effect before receipt of this Order have priority unless the IRS agrees otherwise. 6. Notice of Work Status: If the Restitution Obligor is not employed by you, is in inactive status (employed but not receiving pay), ceases to work for you, or becomes reemployed by you, you must notify this Court and P&P or DJS in writing. If the Restitution Obligor, ceases to work for you, provide P&P or DJS with Restitution Obligor's last known address and the name and address of Restitution Obligor's new employer, if known. 7. Withholding Limits: You may not withhold more than allowed under Federal Consumer Credit Protection Act (15 U.S.C. § 1673(a)) or limits of the state where this Order is served, whichever results in less money being held. Under federal law, the limit is the lesser of 25% of the disposable earnings for a week or 30 times the federal minimum wage. If the amount that you are required to withhold under this Order, together with support and other withholdings required by law, exceeds the limit under this section, you must notify this Court and P&P or DJS immediately. NOTICE TO RESTITUTION OBLIGOR 1. Objections: You must notify this Court and P&P or DJS if you have any objection to this Order. 2. Changes in residence or employment: You must immediately notify this Court and P&P or DJS of each change in residence, employment, and/or work address. 3 Liability: If you fail to give notice, you are subject to a fine. CC-DC/CR 84 (Rev. 4/2008) American LegalNet, Inc. www.FormsWorkflow.com