Original - Court 1st copy - Employee 2nd copy - Employer Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT CASE NO. ORDER FOR ASSIGNMENT OF WAGES Court address Court telephone no. In the matter of Name of employee Date of birth Last four digits of social security no. or employee ID no. Address City State Zip Telephone no. IT IS ORDERED pursuant to MCL 769.1k: 1. Name Address employer, shall withhold from the earnings due the person named above the amount of $ per , effective one week after service upon the employer of a copy of this order. The employer shall indicate the case number on the withholding and shall forward the withholding to the court at the above address. 2. The employer shall not use this assignment as a basis, in whole or in part, for the discharge of the employee or for any other disciplinary action against the employee. 3. Your compliance with this order is required by law. 4. This order shall remain in full force and effect until further order of the court or until the total of $ most recent balance been withheld, whichever comes first. Date Judge has Bar no. NOTE: Wage assignment is a transfer of the right to receive wages, ordinarily effected by means of a contract. As such, wage assignments are not within the scope of the federal wage garnishment law. For purposes of this order, however, wages have been defined based on the federal wage garnishment law. Wages are defined as earnings or compensation paid for personal services whether called wages, salary, commission, bonus, or otherwise, and can include periodic payments under a pension or retirement program. (Title III, Section 302, PL 90-321) When required, withholdings shall be determined using the calculation sheet from SCAOApproved form MC 14 (Garnishee Disclosure). CERTIFICATE OF MAILING I certify that on this date copies of this order were served on the employee and employer by first-class mail to their last-known addresses. Date MC 289 (5/07) Signature ORDER FOR ASSIGNMENT OF WAGES MCL 769.1k, MCL 771.3(2)(f) American LegalNet, Inc. www.FormsWorkflow.com