PAYMENT TO AVOID GARNISHMENT NEW PHILADELPHIA MUNICIPAL COURT 166 East High Avenue New Philadelphia, Ohio 44663 330-343-6797 330-364-6885 FAX To: Date of Mailing: Time Stamp (Name of judgment debtor) (Last known residence address of the judgment debtor) (City) (State) (Zip Code) CASE NO. To avoid garnishment of PERSONAL EARNINGS of which you have given me notice, I enclose $ apply toward my indebtedness to you. The amount of the payment was computed as follows: 1. 2. 3 4. 5. Total amount of indebtedness demanded Enter the amount of your personal earnings after deductions required by law earned by you during the current pay period (that is, the pay period in which this demand is received by you) (A) Enter your pay period (weekly, biweekly, semimonthly, monthly) (B) Enter the date when your present pay period ends Enter an amount equal to 25% of the amount on line (2) (A) (You should use the above figure to complete this portion of the form). If you are paid weekly, enter thirty (30) times the current federal minimum hourly wage; if paid biweekly, enter sixty (60) times the current federal minimum hourly wage; if paid semimonthly, enter sixty-five (65) times the current federal minimum hourly wage; if paid monthly, enter one hundred thirty (130) times the current federal minimum hourly wage. (B) Enter the amount by which the amount on line (2) exceeds the amount on line 5(A) Enter the smallest of the amounts on line 1, 4 or 5(B). Send this amount to the Judgment Creditor along with this form after you have signed it. I certify that the statements contained above are true to the best of my knowledge and belief: , to 6. (Signature of Judgment Debtor) (Print Name and Residence Address of Judgment Debtor) City State Zip Code (To verify that the amount shown on line 2. is a true statement of your earnings, you must either have your employer certify below that the amount shown on line 2. is a true statement of your earnings or you may submit copies of your pay stubs for the two pay periods immediately prior to your receiving this notice.) I certify that the amount shown on line 2 is a true statement of the judgment debtor's earnings. (Signature of Employer or Agent) (Print name of Employer) I certify that I have attached copies of my pay stubs for the two pay periods immediately prior to my receiving this notice. (Signature of Judgment Debtor) American LegalNet, Inc. www.FormsWorkFlow.com PAYMENT TO AVOID GARNISHMENT 11/2015 JAS